ECT and Human Memory – Recent MEDLINE Citations

By, Ivan K. Goldberg, M.D.

1. Psychol Med. 2010 Jun;40(6):1017-25. Epub 2009 Sep 24.

Using the Cambridge Neuropsychological Test Automated Battery (CANTAB) to assess
the cognitive impact of electroconvulsive therapy on visual and visuospatial

Falconer DW, Cleland J, Fielding S, Reid IC.

Department of Mental Health, Clinical Research Centre, Royal Cornhill Hospital,
University of Aberdeen, Aberdeen AB25 2ZH, UK.

BACKGROUND: The cognitive impact of electroconvulsive therapy (ECT) is rarely
measured systematically in everyday clinical practice even though patient and
clinician acceptance is limited by its adverse affect on memory. If patients are
tested it is often with simple paper and pencil tests of visual or verbal memory.
There are no reported studies of computerized neuropsychological testing to
assess the cognitive impact of ECT on visuospatial memory. METHOD: Twenty-four
patients with severe depression were treated with a course of bilateral ECT and
assessed with a battery of visual memory tests within the Cambridge
Neuropsychological Test Automated Battery (CANTAB). These included spatial and
pattern recognition memory, pattern-location associative learning and a delayed
matching to sample test. Testing was carried out before ECT, during ECT, within
the week after ECT and 1 month after ECT. RESULTS: Patients showed significant
impairments in visual and visuospatial memory both during and within the week
after ECT. Most impairments resolved 1 month following ECT; however, significant
impairment in spatial recognition memory remained. This is one of only a few
studies that have detected anterograde memory deficits more than 2 weeks after
treatment. CONCLUSIONS: Patients receiving ECT displayed a range of visual and
visuospatial deficits over the course of their treatment. These deficits were
most prominent for tasks dependent on the use of the right medial temporal lobe;
frontal lobe function may also be implicated. The CANTAB appears to be a useful
instrument for measuring the adverse cognitive effects of ECT on aspects of
visual and visuospatial memory.
PMID: 19775495 [PubMed – indexed for MEDLINE] 2. CNS Spectr. 2010 May;15(5):304-13.

Evaluation of the Effects od Severe Depression on Global Cognitive Function and

McClintock SM, Cullum M, Husain MM, Rush AJ, Knapp RG, Mueller M, Petrides G,
Sampson S, Kellner CH.

University of Texas Southwestern Medical Center, Dallas, TX 75390-8898, USA.

INTRODUCTION: Major depressive disorder (MDD) is thought to negatively impact
cognitive function; however, the relationship has not been well explored.
OBJECTIVE: This study examined the association between depression severity and
global cognitive function and memory in subjects with severe, treatment-resistant
MDD. METHODS: We enrolled 66 subjects with Structured Clinical Interview for the
Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosed
unipolar MDD in a multicenter trial to assess the efficacy and neurocognitive
effects of electroconvulsive therapy (ECT). We measured depression severity with
the 24 item Hamilton Rating Scale for Depression (HRSD(24)). Neuropsychologic
measures included the Mini Mental State Examination (MMSE), Rey Auditory Verbal
Learning Test (RAVLT), and the Complex Figure Test (CFT). Correlational and
regression analyses were conducted to explore associations between depression
severity and cognitive function. RESULTS: The mean age of the subjects was 53.6
years (SD=15.8), 65% were female, and mean HRSD(24) was 33.9 (SD=6.7). Mean
demographic-corrected T-scores for each neurocognitive measure were in the
average to borderline range, and HRSD(24) values were unrelated to performance on
the MMSE, RAVLT immediate and delayed recall, and CFT immediate and delayed
recall. CONCLUSION: In this sample of severely depressed subjects referred for
ECT, depression severity was unrelated to global cognitive function or memory.
Future research should examine the interactions between other depressive
characteristics and neurocognitive function.
PMID: 20448521 [PubMed – indexed for MEDLINE] 3. Med Hypotheses. 2010 May;74(5):780-1. Epub 2009 Dec 14.

Nitrous oxide (laughing gas) inhalation as an alternative to electroconvulsive

Milne B.

Department of Anesthesiology and Perioperative Medicine, Queen’s University,
Kingston General Hospital, Kingston, ON, Canada.

Electroconvulsive therapy (ECT) is used widely in the treatment of psychiatric
conditions; however, its use is not without controversy with some recommending a
moratorium on its clinical use. Complications and side effects of ECT include
memory loss, injury, problems originating from sympathetic stimulation such as
arrhythmias and myocardial ischemia and the risk of general anesthesia. Nitrous
oxide (laughing gas) could potentially substitute for ECT as it shares some
similar effects, has potential beneficial properties for these psychiatric
patients and is relatively safe and easy to administer. Nitrous oxide induces
laughter which has been described as nature’s epileptoid catharsis which one
might surmise would be beneficial for depression. It also produces a central
sympathetic stimulation similar to ECT and causes release of endogenous opioid
peptides, which are potential candidates for the development of antidepressant
drugs. Nitrous oxide is also associated with seizure like activity itself.
Administration of nitrous oxide as a substitute for ECT is eminently feasible and
could be given in a series of treatments similar to ECT therapy.
PMID: 20006916 [PubMed – indexed for MEDLINE] 4. J Affect Disord. 2010 Apr;122(1-2):60-7. Epub 2009 Jul 5.

Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive
therapy for major depression: cognitive side-effects.

Sienaert P, Vansteelandt K, Demyttenaere K, Peuskens J.

ECT Department, University Psychiatric Center, Catholic University of Leuven,
campus Kortenberg, Leuvensesteenweg 517, 3070 Kortenberg, Belgium.

OBJECTIVE: The cognitive side-effects of bifrontal (BF) and right unilateral (UL)
ultra-brief pulse (0.3 ms) electroconvulsive therapy (ECT) were compared, in the
treatment of patients with a depressive episode. METHOD: Neuropsychological
functioning in patients with a medication refractory depressive episode, that
were treated with a course of BF ultra-brief ECT at 1.5 times seizure threshold
(ST) or UL ultra-brief ECT at 6 times ST, by random assignment, was assessed
before treatment, and 1 and 6 weeks after the treatment course, by a blinded
rater. RESULTS: Of the 64 patients that were included, 32 (50%) received BF ECT,
and 32 (50%) received UL ECT, by random assignment. Neuropsychological testing 1
and 6 weeks after treatment was performed by 30 (93.75%) and 19 (59.37%)
patients, respectively, in the BF-group and 29 (90.62%) and 20 (62.50%),
respectively, in the UL-group. There was no deterioration in any of the
neuropsychological measures. Patients rated their memory as clearly improved
after treatment. There were no significant differences between the patients given
BF ECT and those given UL ECT. CONCLUSIONS: Ultrabrief pulse ECT, used either in
combination with a UL electrode position and a stimulus of 6 times ST, or a BF
electrode position with a stimulus of 1.5 times ST, are effective antidepressant
techniques, that do not have a deleterious effect on cognitive function.
PMID: 19577808 [PubMed – indexed for MEDLINE] 5. World J Biol Psychiatry. 2010 Apr;11(3):525-37.

Electroconvulsive therapy: a review of knowledge, experience and attitudes of
patients concerning the treatment.

Chakrabarti S, Grover S, Rajagopal R.

Department of Psychiatry, Postgraduate Institute of Medical Education and
Research, Chandigarh, India.

OBJECTIVES: Despite its proven efficacy and safety, electroconvulsive therapy
(ECT) has a negative image and attracts widespread public criticism. In contrast,
perceptions of patients who have received ECT appear to be more favourable. This
review intended to encapsulate the evidence on knowledge and views concerning ECT
among its recipients. METHODS: Extensive electronic and manual searches were
conducted to identify all relevant studies on the subject. RESULTS: Seventy-five
reports were found suitable. The evidence from these studies suggested that
patients undergoing ECT were usually poorly informed about it. This was
attributable to factors such as unsatisfactory pre-treatment explanations or
post-ECT memory impairment. About one-third undergoing ECT reported feeling
coerced to have the treatment. Fear of ECT and distressing side effects were also
present in a majority. Despite these problems, a vast majority of patients
perceived ECT to be helpful and had positive views regarding the treatment.
Simultaneously, a sizeable proportion was quite critical, although little was
known about the extent and nature of such disapproval. CONCLUSIONS: Overall, the
weight of the evidence supports the notion that patients undergoing ECT are
well-disposed towards it. However, much needs to be done to improve the practice
of ECT and to enhance patients’ satisfaction with the experience of treatment.
PMID: 20128713 [PubMed – indexed for MEDLINE] 6. Br J Psychiatry. 2010 Mar;196:171-2.

Electroconvulsive therapy, practice and evidence.

Scott AI.

Comment on:
Br J Psychiatry. 2010 Mar;196:226-34.

This issue includes the findings from the largest randomised controlled trial
ever conducted with bilateral, unilateral and bifrontal electroconvulsive therapy
(ECT). The background to the study and its findings are discussed.
PMID: 20194535 [PubMed – indexed for MEDLINE] 7. J ECT. 2010 Mar;26(1):23-9.

The safety and efficacy of benzodiazepine-modified treatments as a special form
of unmodified ECT.

Shah N, Mahadeshwar S, Bhakta S, Bhirud M, Fernandes P, Andrade C.

Department of Psychiatry, Lokmanya Tilak Municipal Medical College and General
Hospital, Sion, Bombay, India.

Erratum in:
J ECT. 2010 Sep;26(3):242.

BACKGROUND: Muscle relaxants reduce musculoskeletal morbidity with
electroconvulsive therapy (ECT) but need to be administered under general
anesthesia. The administration of anesthesia is not always possible for patients
prescribed ECT. Consequently, unmodified ECT is still widely practiced,
especially in developing countries. METHODS: We prospectively assessed
musculoskeletal morbidity in consecutive patients who received unmodified
bitemporal ECT during a part or the whole of their ECT course. All patients were
pretreated with an intravenous benzodiazepine (usually diazepam, 10 mg) to effect
sedation, anxiolysis, and limited skeletal muscle relaxation. Anteroposterior and
lateral digital x-rays of the thoracolumbar spine were obtained after the last
unmodified treatment. RESULTS: Fifty-six patients aged 11 to 49 years and with a
mean body mass index of 23.0 received a total of 162 (mean, 2.9) unmodified ECTs.
There was significant attenuation of psychopathology ratings. Against our
expectations, no patient developed clinical or radiological evidence of
orthopedic morbidity; however, in 2 patients, the x-rays revealed old spinal
fractures. Twelve patients had spots of oral bleeding after ECT. Whereas 5
patients experienced mild, transient, self-limiting postictal confusion, only one
had confusion which required medical termination. Five patients complained of
body ache and one of memory impairment. There were no other adverse events.
CONCLUSIONS: The complete absence of orthopedic morbidity with
benzodiazepine-modified ECT contrasts with historical descriptions of a 20% to
40% risk with unmodified ECT. We speculate that the limited muscle relaxant
action of the pre-ECT parenteral benzodiazepine may have had protective effects.
If so, if ECT is urgently indicated but anesthesia and hence conventional muscle
relaxants cannot be administered, benzodiazepine-modified ECT may be a safer
alternative to unmodified ECT. This suggestion merits wide attention because of
its public health importance in countries with poor medical infrastructure, where
unmodified ECT is still widely practiced.
PMID: 20190597 [PubMed – indexed for MEDLINE] 8. J ECT. 2010 Mar;26(1):16-22.

The depiction of electroconvulsive therapy in Hindi cinema.

Andrade C, Shah N, Venkatesh BK.

Department of Psychopharmacology, National Institute of Mental Health and
Neurosciences, Bangalore.

BACKGROUND: There is little literature on the depiction of electroconvulsive
therapy (ECT) in movies. In India, Hindi cinema is an important source of public
information and misinformation about ECT. METHODS: We identified depictions of
ECT in Hindi cinema through inquiries with e-communities, video libraries, and
other sources. We also searched the PubMed database using search terms related to
ECT and movies. RESULTS: Between 1967 and 2008, 13 Hindi movies contained
referrals to or depictions of ECT. By and large, the depictions were inaccurate,
distorted, and dramatized. Electroconvulsive therapy was administered to punish,
to obliterate identity, to induce insanity, and for other rarely clinically valid
indications. Electroconvulsive therapy was almost always administered by force.
Premedication was rare. Genuine ECT devices were uncommonly used.
Electroconvulsive therapy stimulation almost invariably appeared to cause pain.
Multiple shocks were frequently delivered in the same session. The convulsions
were usually bizarre. The treatment caused mental disturbance, amnesia, weakness,
and even a zombielike state, thought not mortality; clinical improvement was
rare. There was no pattern of increasing accuracy of depiction of ECT with
recency of movie release. DISCUSSION: We examine the extent to which the
identified inaccuracies are practically important and offer reasons for the
inaccuracies. Although the inaccuracies are a cause for concern, we suggest that
because Hindi cinema is generally hyperbolic, the public may be willing to
distinguish real life from reel life when facing clinical decisions about ECT.
Nevertheless, considering the potential for harm in the dissemination of
misinformation, filmmakers should exhibit a greater sense of ethics when creating
impressions that might adversely influence health.
PMID: 20190596 [PubMed – indexed for MEDLINE] 9. J ECT. 2010 Mar;26(1):47-52.

Pre- and post-electroconvulsive therapy multidomain cognitive assessment in
psychotic depression: relationship to premorbid abilities and symptom

Bayless JD, McCormick LM, Brumm MC, Espe-Pfeifer PB, Long JJ, Lewis JL.

Department of Psychiatry, University of Iowa, Carver College of Medicine, Iowa
City, IA 52242, USA.

OBJECTIVES: Cognitive changes have been reported in patients after
electroconvulsive therapy (ECT), but few studies have investigated post-ECT
changes across multiple cognitive domains. Because cognitive dysfunction is
presumed to be more salient in psychotic depression, we propose a brief pre-ECT
multidomain cognitive assessment battery, assessing neurocognitive function in
this population before and after ECT. We also compared performance to estimated
premorbid levels and determined if neuropsychological functioning was related to
symptom improvement. METHODS: Twenty participants with psychotic depression (12
females, 8 males) undergoing ECT for severe depression received the repeatable
battery for the assessment of neuropsychological status (RBANS) and additional
tasks. The wide range achievement test reading test provided an estimate of
premorbid intellectual functioning. Depressive symptoms were assessed with the
Hamilton Depression Scale-28, whereas negative and positive symptoms were
assessed with the Scale for Assessing Negative and Positive Symptoms. RESULTS:
There was a significant improvement in depressive symptoms with most measures of
cognitive function showing net gains. When cognitive performances were compared
with estimated premorbid abilities, findings indicated significant movement
toward normalization in overall RBANS score, particularly involving the language
index and attention index. Considered individually, 6 (30%) participants showed
pre-ECT cognitive dysfunction (RBANS total score 6 months
post-ECT). Electroconvulsive therapy predominantly affects memory of prior
personal events that are near the treatment (within 6 months). Autobiographical
memory loss is reduced by using brief pulse ECT rather than sine wave-unilateral
positioning of electrodes rather than bilateral-and by titrating electrical
current relative to the patient’s own seizure threshold. CONCLUSIONS: Further
research is required to determine memory loss associated with ECT, controlling
for the direct effects of the depressive state.
PMID: 18379329 [PubMed – indexed for MEDLINE] 40. J ECT. 2008 Mar;24(1):3-9.

Cognitive side effects of brief pulse electroconvulsive therapy: a review.

Ingram A, Saling MM, Schweitzer I.

Department of Psychology, University of Melbourne, Victoria, Australia.

Cognitive impairment remains a common side effect of brief pulse
electroconvulsive therapy (ECT), and its minimization has been the motivation for
many different treatment modifications over the decades. The level of impairment
has been shown to vary according to different technical parameters of ECT
including, but not limited to, electrode placement, dosage, and waveform, as well
as patient factors, such as age and premorbid intellect. Most past research has
focused the assessment on memory impairments associated with ECT. Specifically,
ECT can result in both anterograde and retrograde memory impairments. However,
the study of non-memory cognitive functions after ECT has been relatively
neglected. Furthermore, although considerable recovery has been observed within
weeks of treatment completion, data are lacking in the longer term. The following
article presents an overview of what is currently known about the pattern and
recovery of cognitive side effects of ECT. Controversies within the literature
and areas requiring further research are highlighted.
PMID: 18379328 [PubMed – indexed for MEDLINE] 41. Curr Pharm Des. 2008;14(13):1274-94.

Central nervous system abnormalities in fibromyalgia and chronic fatigue
syndrome: new concepts in treatment.

Gur A, Oktayoglu P.

Department of Physical Medicine and Rehabilitation, Medical Faculty, Dicle
University, 21280 Diyarbakir, Turkey.

Fibromyalgia (FM) and chronic fatigue syndrome (CFS) are poorly understood
disorders that share similar demographic and clinical characteristics. The
etiology and pathophysiology of these diseases remain unclear. Because of the
similarities between both disorders it was suggested that they share a common
pathophysiological mechanisms, namely, central nervous system (CNS) dysfunction.
Current hypotheses center on atypical sensory processing in the CNS and
dysfunction of skeletal muscle nociception and the hypothalamic-pituitary-adrenal
(HPA) axis. Researches suggest that the (CNS) is primarily involved in both
disorders in regard to the pain, fatigue and sleep disturbances. Many patients
experience difficulty with concentration and memory and many others have mood
disturbance, including depression and anxiety. Although fibromyalgia is common
and associated with substantial morbidity and disability, there are no US Food
and Drug Administration (FDA)-approved treatments except pregabalin. Recent
pharmacological treatment studies about fibromyalgia have focused on selective
serotonin and norepinephrine (NE) reuptake inhibitors, which enhance serotonin
and NE neurotransmission in the descending pain pathways and lack many of the
adverse side effects associated with tricyclic medications. CFS is a descriptive
term used to define a recognisable pattern of symptoms that cannot be attributed
to any alternative condition. The symptoms are currently believed to be the
result of disturbed brain function. To date, no pharmacological agent has been
reliably shown to be effective treatment for CFS. Management strategies are
therefore primarily directed at relief of symptoms and minimising impediments to
recovery. This chapter presents data demonstrating CFS, abnormal pain processing
and autonomic nervous system (ANS) dysfunction in FM and CFS and concludes by
reviewing the new concepts in treatments in CFS and FM.
PMID: 18537652 [PubMed – indexed for MEDLINE] 42. J ECT. 2007 Dec;23(4):255-9.

Patients’ and their relatives’ attitudes toward electroconvulsive therapy in
bipolar disorder.

Virit O, Ayar D, Savas HA, Yumru M, Selek S.

Department of Psychiatry, Faculty of Medicine, University of Gaziantep,
Gaziantep, Tokat, Turkey.

Although electroconvulsive therapy (ECT) is a safe and efficacious treatment,
there is a widespread negative view of ECT in public and professional circles.
Previous studies that reported psychiatric patients’ and their relatives’
feelings and attitudes toward ECT revealed generally positive results. However,
there are no data focusing on bipolar patients’ and their relatives’ attitudes
toward ECT. In this study, the perspectives of 70 bipolar patients and their 70
relatives were examined before ECT. The study showed that the majority of
patients and relatives believed they had not received adequate information about
ECT, but they were satisfied with the treatment, found it beneficial, and
maintained a positive attitude toward its use. The most commonly reported side
effect was memory impairment. This is the first study focusing on bipolar
patients’ and their relatives’ attitudes toward ECT in the literature.
PMID: 18090699 [PubMed – indexed for MEDLINE] 43. J Affect Disord. 2007 Nov;103(1-3):277-81. Epub 2007 Aug 16.

A report on mood and cognitive outcomes with right unilateral ultrabrief
pulsewidth (0.3 ms) ECT and retrospective comparison with standard pulsewidth
right unilateral ECT.

Loo C, Sheehan P, Pigot M, Lyndon W.

School of Psychiatry, University of N.S.W., Australia.

BACKGROUND: Electroconvulsive therapy (ECT) is a highly effective treatment for
depression but its use is limited by the risk of cognitive side effects. This
study explored the potential of a novel approach, ultrabrief pulsewidth (0.3 ms)
right unilateral (RUL-UB) ECT, to minimise cognitive effects while preserving
efficacy. METHODS: Mood and neuropsychological functioning were objectively rated
in 30 patients over a course of RUL-UB ECT at 6 times seizure threshold. Results
(mood outcomes, ECT treatment parameters) were compared with a retrospectively
assessed group of 30 age and gender matched patients who received RUL ECT (1.0 ms
pulsewidth, 3.5 times seizure threshold) at the same hospital. RESULTS: Six
treatments of RUL-UB ECT resulted in relatively few cognitive side effects,
compared to reports of previous studies. The number of responders did not differ
between groups but significantly more treatments were required in the RUL-UB
group, suggesting a slower speed of response. LIMITATIONS: Patients were not
randomised to the two forms of ECT and data was obtained retrospectively in the
RUL ECT comparison group. CONCLUSIONS: This study suggests that RUL-UB ECT can be
effective in treating depression while incurring lesser cognitive side effects
than a commonly used form of RUL ECT, but a greater number of treatments may be
required for response.
PMID: 17706790 [PubMed – indexed for MEDLINE] 44. J Affect Disord. 2007 Nov;103(1-3):263-6. Epub 2007 Feb 27.

The effects of electro-convulsive therapy on the speed of information processing
in major depression.

Tsourtos G, Spong J, Stough C.

Department of Public Health, Flinders University of South Australia, Australia.

BACKGROUND: This study investigates whether cognitive impairment is evident in
inpatients diagnosed with Major Depression (MD) following electro-convulsive
therapy (ECT), and if so, whether it is independent from depressive
symptomatology. METHODS: Speed of information processing was measured using the
inspection time (IT) task. IT was compared between twelve inpatients diagnosed
with MD receiving ECT and twelve age-, gender-, verbal IQ-, and depression and
anxiety severity matched control inpatients diagnosed with MD not receiving ECT,
over four testing sessions (prior to ECT, following one ECT session, following
the completion of an ECT block, and 4 to 6 weeks after the ECT block
(follow-up)). RESULTS: The mean IT score for the inpatients diagnosed with MD who
received ECT slowed significantly from the first ECT to immediately after the ECT
block, and was significantly faster at follow-up. The mean IT score of the
inpatients diagnosed with MD not receiving ECT gradually but significantly became
faster over the entire equivalent time period. LIMITATIONS: Small sample sizes.
CONCLUSIONS: ECT temporarily slows information processing speed in MD patients,
independent of depression symptomatology.
PMID: 17328957 [PubMed – indexed for MEDLINE] 45. Pain. 2007 Nov;132(1-2):206-10. Epub 2007 Aug 30.

Sudden amnesia resulting in pain relief: the relationship between memory and

Choi DS, Choi DY, Whittington RA, Nedeljkovi? SS.

Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical
School, Brigham and Women’s Hospital, Boston, MA, USA.

Comment in:
Pain. 2007 Nov;132(1-2):16-7.

Nociceptive pain and its emotional component can result in the development of a
“chronic pain memory”. This report describes two patients who had long histories
of chronic pain and opioid dependence. Both patients experienced sudden memory
loss that was followed by significant pain reduction and an eradication of their
need for opioid management. Neural centers involved in sensory pain, its
affective component, opioid dependence, and memory overlap in the brain and share
common pathways. The anterior cingulate cortex, the insular cortex, and the
amygdala are examples of regions implicated in both pain and memory. One of the
patients in the report experienced multiple seizure episodes, which may have
contributed to memory loss and pain relief. The role of electroconvulsive therapy
as it relates to amnesia and pain is reviewed. Questions are raised regarding
whether therapies that address the memory component of pain may have a role in
the treatment of long-term chronic pain patients.
PMID: 17764843 [PubMed – indexed for MEDLINE] 46. J ECT. 2007 Sep;23(3):201-3.

Unilateral nondominant electrode placement as a risk factor for recall of
awareness under anesthesia during electroconvulsive therapy.

Andrade C, Thirthalli J, Gangadhar BN.

Department of Psychopharmacology, National Institute of Mental Health and
Neurosciences, Bangalore, India.

BACKGROUND: Awareness under anesthesia can be a frightening experience for
patients receiving electroconvulsive therapy (ECT). CASE REPORT: We present a
19-year-old, 62-kg, bipolar woman who was prescribed right unilateral ECT for a
treatment-refractory major depressive episode. Her premedication comprised
thiopentone sodium (200 mg) and succinylcholine (30 mg). She received 3
treatments uneventfully. A day after the fourth treatment, she described her
awareness of paralysis during the last procedure and refused further treatment
despite the marked improvement that had resulted with ECT. DISCUSSION:
Electroconvulsive therapy is more usually administered with bilateral than with
unilateral electrode placement. During ECT, awareness under anesthesia and recall
of paralysis (resulting from inadequate doses of anesthesia and/or premature
administration of the muscle relaxant) may be more common than is generally
realized but may not be reported by patients because bilateral ECT tends to
obliterate the memory of the ECT procedure. If this is true, unilateral
nondominant ECT, which is relatively memory sparing, may increase the chance of
recollection of paralysis when narcosis under anesthesia is incomplete. Careful
clinical assessment and monitoring of the depth of anesthesia using the
bispectral index can minimize this risk of awareness under anesthesia.
PMID: 17805001 [PubMed – indexed for MEDLINE] 47. J ECT. 2007 Sep;23(3):169-74.

A questionnaire study of patients’ experience of electroconvulsive therapy.

Myers DH.

Shelton Hospital, Shrewsbury, UK.

OBJECTIVE: To ascertain patients’ experience of electroconvulsive therapy (ECT)
using a questionnaire having these features: short so to be acceptable to the
elderly and the depressed; ascertaining experience, not opinions; coming from a
‘neutral’ source; and analyzed by methods that do not impose an arbitrary scale
on ordinal response categories. METHOD: Two hundred eighty-eight traceable
patients consecutively treated with ECT were surveyed, the majority by post. One
hundred forty-eight replied. RESULTS: The conviction, a median of 4 years after
ECT, that side effects persisted was related to current depression and,
inversely, to age, but not to the number of ECT given. Current depression was
also associated with a less favorable account of emotional support during ECT.
Formal legal status had no effect on any of the answers, but refusal of, or
agreement to ECT on sufferance, was linked to a relatively unfavorable view of
it. Not all patients regarded the decision to give them ECT compulsorily wrong on
principle; some judged by results. CONCLUSIONS: The degree of current depression
contributes to several aspects of the patient’s view of ECT given a median of 4
years earlier. The belief that side effects persist has a complex basis; but the
importance of this belief is not thereby diminished. Legal compulsion of
treatment adds its own quota of contention which can be mitigated, but not
entirely dispelled, by careful adherence to the law.
PMID: 17804991 [PubMed – indexed for MEDLINE] 48. J ECT. 2007 Sep;23(3):163-8.

Ictal electroencephalographic correlates of posttreatment neuropsychological
changes in electroconvulsive therapy: a hypothesis-generation study.

Azuma H, Fujita A, Otsuki K, Nakano Y, Kamao T, Nakamura C, Fujioi J, Otake H,
Nishigaki M, Suzuki M, Kataoka M, Matsuzawa T, Sonoda M, Nakaaki S, Murata Y,
Akechi T, Furukawa TA.

Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City
University Graduate School of Medical Sciences, Nagoya, Japan.

OBJECTIVES: Electroconvulsive therapy (ECT) has been associated with memory and
neuropsychological changes, but which features of ECT are associated with those
changes have not been well investigated. The aim of this hypothesis-generation
study was to examine correlations between ictal electroencephalographic (EEG)
characteristics and cognitive side effects after ECT. METHODS: Eight patients
with major depressive disorder were examined with the Wechsler Memory
Scale-Revised (WMS-R), the Stroop test, the Trail Making Test, and verbal fluency
before and after ECT treatment. Seven ictal EEG measurements (eg, slow-wave phase
amplitude, postictal suppression) were manually rated by 3 independent
psychiatrists. The correlations between ictal EEG measurements, changes in WMS-R
subset scores, and non-memory-related neuropsychological assessments were
examined with Spearman rank correlation. RESULTS: Verbal memory, general memory,
attention/concentration, delayed memory of WMS-R subset scores, and the Stroop
test scores improved significantly after ECT treatment. Postictal suppression and
slow-wave amplitude correlated positively with delayed memory and visual/verbal
discrepancy score. Slow-wave amplitude correlated negatively with letter fluency.
The longer the polyspike wave duration, the higher the attention/concentration
test results. CONCLUSIONS: Certain ictal EEG measurements were associated with
changes in several neuropsychological test results that had improved 2 weeks
after the final ECT treatment. A hypothesis-testing study with a larger sample is
needed to verify the relationships between EEG measurements and
neuropsychological test performance.
PMID: 17804990 [PubMed – indexed for MEDLINE] 49. J ECT. 2007 Sep;23(3):153-7.

Changes in everyday and semantic memory function after electroconvulsive therapy
for unipolar depression.

Schat A, van den Broek WW, Mulder PG, Birkenhäger TK, van Tuijl R, Murre JM.

Department of Psychology, University of Amsterdam, Amsterdam, The Netherlands.

OBJECTIVES: This long-term prospective study focuses on the effects of
electroconvulsive therapy (ECT) on everyday memory function and on semantic
memory function. METHODS: Results of memory test from 96 consecutive inpatients
treated for unipolar depression were analyzed prospectively before ECT, after ECT
treatment, and at 3- and 12-month follow-up. Everyday memory function was
assessed by means of the Rivermead Behavioural Memory Test (RBMT) and semantic
memory by 2 forms of the word fluency test. RESULTS: In our study, age had a
constant and significant negative effect on everyday memory (RBMT score) over
time. Bilateral electrode placement mainly influenced everyday memory, which was
significantly improved at 3-month follow-up. One year after discharge, the RBMT
scores were not significantly different from pretreatment levels, indicating that
ECT does not affect everyday memory on the longer term. Scores on both word
fluency tests for semantic memory were significantly influenced by age over time.
The effect of age changed from a negative influence directly after ECT to a
positive effect at follow-up. This advantage of higher age indicates that the
semantic memory of older patients receiving ECT for severe mood disorder shows
greater improvement at follow-up compared with younger patients. Over time, the
scores on only 1 of the word fluency tests were significantly influenced by
mainly bilateral electrode placement. CONCLUSIONS: A small but reversible
decrease in everyday memory occurs after ECT in depressed patients, which is
influenced by age and electrode placement. Semantic memory shows a fluctuating
but recovering course, which is also influenced by age and electrode placement.
During follow-up, the improvement in semantic memory was greater in the older
PMID: 17804988 [PubMed – indexed for MEDLINE] 50. Nat Neurosci. 2007 Sep;10(9):1116-24.

Targeting abnormal neural circuits in mood and anxiety disorders: from the
laboratory to the clinic.

Ressler KJ, Mayberg HS.

Department of Psychiatry and Behavioral Sciences, Emory University School of
Medicine, 954 Gatewood Drive, Atlanta, Georgia 30329, USA.

Recent decades have witnessed tremendous advances in the neuroscience of emotion,
learning and memory, and in animal models for understanding depression and
anxiety. This review focuses on new rationally designed psychiatric treatments
derived from preclinical human and animal studies. Nonpharmacological treatments
that affect disrupted emotion circuits include vagal nerve stimulation, rapid
transcranial magnetic stimulation and deep brain stimulation, all borrowed from
neurological interventions that attempt to target known pathological foci. Other
approaches include drugs that are given in relation to specific learning events
to enhance or disrupt endogenous emotional learning processes. Imaging data
suggest that common regions of brain activation are targeted with pharmacological
and somatic treatments as well as with the emotional learning in psychotherapy.
Although many of these approaches are experimental, the rapidly developing
understanding of emotional circuit regulation is likely to provide exciting and
powerful future treatments for debilitating mood and anxiety disorders.
PMCID: PMC2444035
PMID: 17726478 [PubMed – indexed for MEDLINE] 51. J Psychiatry Neurosci. 2007 Jul;32(4):241-9.

The long-term impact of treatment with electroconvulsive therapy on discrete
memory systems in patients with bipolar disorder.

MacQueen G, Parkin C, Marriott M, Bégin H, Hasey G.

Mood Disorder Program, St. Joseph’s Healthcare, McMaster University, Hamilton,

OBJECTIVE: Electroconvulsive therapy (ECT) has been controversially associated
with long-lasting memory problems. Verbal learning and memory deficits are
commonly reported in studies of people with bipolar disorder (BD). Whether memory
deficits can be exacerbated in patients with BD who receive ECT has, to our
knowledge, not been systematically examined. We aimed to examine whether
long-term effects of ECT on discrete memory systems could be detected in patients
with BD. METHODS: We studied several domains of memory in 3 groups of subjects
who were matched for age and sex: a group of healthy comparison subjects, a group
of people with BD who had received ECT at least 6 months before memory assessment
and another group with BD that had an equal past illness burden but had never
received ECT. Memory was assessed with the California Verbal Learning Test, the
Continuous Visual Memory Test and a computerized process dissociation task that
examines recollection and habit memory in a single paradigm. RESULTS: Compared
with healthy subjects, patients had verbal learning and memory deficits. Subjects
who had received remote ECT had further impairment on a variety of learning and
memory tests when compared with patients with no past ECT. This degree of
impairment could not be accounted for by illness state at the time of assessment
or by differential past illness burden between patient groups. CONCLUSIONS: From
a clinical perspective, it is unlikely that such findings, even if confirmed,
would significantly change the risk-benefit ratio of this notably effective
treatment. Nonetheless, they may highlight the importance of attending to
cognitive factors in patients with BD who are about to receive ECT; further, they
raise the question of whether certain strategies that minimize cognitive
dysfunction with ECT should be routinely employed in this patient group.
PMCID: PMC1911194
PMID: 17653292 [PubMed – indexed for MEDLINE] 52. J ECT. 2007 Jun;23(2):78-81.

Electroconvulsive therapy: the practice and training needs of referring
psychiatrists in the United Kingdom and Republic of Ireland.

Blaj A, Worrall A, Chaplin R.

Complex Cases Service, Psychotherapy Department, Addenbrooke’s Hospital,
Cambridge, UK.

This study aims to gain a greater understanding of the clinical practice and
training needs of psychiatrists who prescribe electroconvulsive therapy (ECT),
including knowledge about ECT, obtaining informed consent, and the monitoring of
patients after ECT. Four hundred ninety psychiatrists who refer patients for ECT
were sent questionnaires as part of reviews conducted by the ECT Accreditation
Service, and 56% responded. Data were analyzed using descriptive statistics and
thematic analysis. Nearly all felt that they had adequate knowledge about ECT
with 35% recognizing further training needs. Psychiatrists were likely to find
difficulty explaining to patients more about how ECT works and the possibility of
long-term cognitive side effects than the benefits of ECT. The main areas of
training need are the obtaining of informed consent, including the choice between
unilateral and bilateral ECT, and the assessment of cognitive function during and
after the course. The study also reveals the need for further research into
long-term cognitive side effects of ECT and the need for a reliable cognitive
assessment tool for measuring persistent or autobiographical memory deficits.
PMID: 17548975 [PubMed – indexed for MEDLINE] 53. Psychiatr Pol. 2007 May-Jun;41(3):339-49.

[Working memory disturbances in patients with major depression after ECT
treatment] [Article in Polish]

Datka W, Siwek M, Dudek D, Maczka G, Zieba A.

Klinika Psychiatrii CM UJ.

INTRODUCTION: Electroconvulsive therapy (ECT) is the most effective treatment in
a variety of psychiatric syndromes (especially mood disorders). However one of
its adverse effects is neurocognitive dysfunction. Declarative memory impairment
after ECT is unquestionable and well investigated. There are only few ambiguous
studies focused on nondeclarative and immediate memory changes during ECT.
METHOD: A study of immediate (working) memory changes in depressed patients
treated with ECT (n=10; bitemporal ECT 3 times a week) or imipramine or
desipramine (150-250 mg/day; n=10) was conducted in patients who fulfilled DSM-IV
criteria for major unipolar depression. Hamilton Depression Rating Scale (HDRS)
and Beck’s Depression Inventory (BDI) were used to assess the efficacy of
antidepressant therapy. Cognitive functions were assessed with neuropsychological
tests: Stroop A and B, TMT (Trial Making) A and B. The patients’ status was
evaluated 1 day before the treatment and 1 day, 2 weeks, 1 month and 6 months
after the first ECT procedure. RESULTS: 1 day after first ECT treatment,
patient’s working memory was slightly impaired, but this was not statistically
significant. Both groups showed statistically significant improvement in working
memory I month after start of treatment. However there were statistically
significant differences between ECT and pharmacologically treated groups at the
first month of therapy. CONCLUSION: ECT treatment only temporally affects working
memory function. The improvement of function may be a result of clinical recovery
from depressant symptomatology.
PMID: 17900050 [PubMed – indexed for MEDLINE] 54. Neurol Res. 2007 Apr;29(3):256-9.

Diffusion weighted MRI in the early phase after electroconvulsive therapy.

Szabo K, Hirsch JG, Krause M, Ende G, Henn FA, Sartorius A, Gass A.

Department of Neurology, Universitätsklinikum Mannheim, University of Heidelberg,
Mannheim, Germany.

Although cognitive side effects may occur after electroconvulsive therapy (ECT),
no structural brain abnormalities have been detected after ECT with conventional
magnetic resonance imaging (MRI). Transient disturbances of memory function are
common findings after ECT indicating functional compromise. Diffusion weighted
imaging (DWI) has been shown to be sensitive to focal tissue changes associated
with compromise of energy metabolism in cerebral ischemia and after prolonged
ictal activity. We used conventional MRI and DWI in an exploratory study
examining ten patients after treatment with ECT, eight of whom experienced
short-lasting memory disturbances. MRI and DWI showed no definite signal
abnormalities on qualitative and quantitative analysis. In three patients,
equivocal marginal DWI hyperintensity was noted in the hippocampal formation.
These findings are in line with previous negative studies using conventional MRI.
Higher resolution DWI and serial imaging may be necessary to visualize possible
minimal signal changes after ECT.
PMID: 17509223 [PubMed – indexed for MEDLINE] 55. Actas Esp Psiquiatr. 2007 Jan-Feb;35(1):40-6.

Long-term effects of electroconvulsive therapy on episodic memory.

Criado JM, Fernández A, Ortiz T.

Instituto R. Coullaut de Psiquiatría, Universidad Complutense de Madrid, 28040
Madrid, Spain.

INTRODUCTION: Current guidelines consider electroconvulsive therapy (ECT) as a
treatment of choice for some depressive disorders; however some psychiatrists are
still reluctant toward using ECT as first choice treatment. This fact is probably
due to its short-term deleterious effects on memory and cognition. OBJECTIVE: To
investigate long-term effects of ECT on anterograde episodic memory. METHODS:
Participants were assigned to three groups: 20 major depression patients
receiving ECT treatment (group A), 28 major depression patients following only
pharmacological therapy (group B) and 26 healthy controls (group C). Group A
patients received three ECT sessions. Memory evaluation consisted of three tests:
list of words, and logical memory I and II. Memory evaluation was performed
before treatment (baseline) and six months post-treatment. RESULTS: Groups A and
B performed at a similar level in baseline evaluation. Post-treatment evaluation
indicated that ECT was associated with a significantly better clinical situation
and improvement in all memory tests. There was also a very strong correlation
between clinical improvement and memory performance. CONCLUSIONS: According to
our results, ECT was not associated with deleterious effects on anterograde
episodic memory. ECT produced faster and significantly higher clinical
improvement, as measured by means of Hamilton Depression Rating Scale, which also
correlates with memory performance.
PMID: 17323224 [PubMed – indexed for MEDLINE] 56. Med Hypotheses. 2007;69(1):67-9. Epub 2007 Mar 26.

Depression and the causal role of specific memory system degenerations: link may
be supported by reported therapeutic benefits of Omega 3 fatty acids.

Frais AT.

University of Leeds, 9 Sandhill Oval, Leeds, United Kingdom.

It is well documented that depressed patients, as a result of their illness,
often experience some difficulties with their memory. This hypothesis suggests a
vice-versa; that it is a gradual impairment and ultimate failure of specific
memory systems that may underpin the onset and continuation of a depressive
illness. So particular memory systems of the brain may have a greater role to
play in clinical depression and associated anxiety than is generally recognised.
A common feature of electroconvulsive therapy (ECT) is that it affects patients’
short-term memory adversely. However, in line with the hypothesis, it is
suggested that the mechanism of action of successful ECT treatment is that it
facilitates the repair and reactivation of particular memory systems. One link
that has some bearing on this hypothesis is that of Omega 3 fish oil. It has in
some cases been observed to aid recovery of depression and possibly prevent
relapse. It has been shown to improve memory.
PMID: 17368750 [PubMed – indexed for MEDLINE] 57. Minn Med. 2007 Jan;90(1):34-5.

Decreased memory loss associated with right unilateral ultra-brief pulse wave

Kim SW, Grant JE, Rittberg BR, Simon JE, Vine CJ, Schulz SC.

Department of Psychiatry, University of Minnesota, USA.

The purpose of this brief article is to share with our colleagues in the
psychiatric community and other physicians information about the efficacy of an
emerging new method of electroconvulsive therapy (ECT) that shows advantages over
existing treatments for depression. Patients treated with the method, ultra-brief
pulse wave ECT, have less memory loss and confusion than those treated with
longer-duration ECT.
PMID: 17305102 [PubMed – indexed for MEDLINE] 58. Neuropsychopharmacology. 2007 Jan;32(1):244-54. Epub 2006 Aug 23.

The cognitive effects of electroconvulsive therapy in community settings.

Sackeim HA, Prudic J, Fuller R, Keilp J, Lavori PW, Olfson M.

Department of Biological Psychiatry, New York State Psychiatric Institute, New
York, NY 10032, USA.

Despite ongoing controversy, there has never been a large-scale, prospective
study of the cognitive effects of electroconvulsive therapy (ECT). We conducted a
prospective, naturalistic, longitudinal study of clinical and cognitive outcomes
in patients with major depression treated at seven facilities in the New York
City metropolitan area. Of 751 patients referred for ECT with a provisional
diagnosis of a depressive disorder, 347 patients were eligible and participated
in at least one post-ECT outcome evaluation. The primary outcome measures,
Modified Mini-Mental State exam scores, delayed recall scores from the Buschke
Selective Reminding Test, and retrograde amnesia scores from the Columbia
University Autobiographical Memory Interview-SF (AMI-SF), were evaluated shortly
following the ECT course and 6 months later. A substantial number of secondary
cognitive measures were also administered. The seven sites differed significantly
in cognitive outcomes both immediately and 6 months following ECT, even when
controlling for patient characteristics. Electrical waveform and electrode
placement had marked cognitive effects. Sine wave stimulation resulted in
pronounced slowing of reaction time, both immediately and 6 months following ECT.
Bilateral (BL) ECT resulted in more severe and persisting retrograde amnesia than
right unilateral ECT. Advancing age, lower premorbid intellectual function, and
female gender were associated with greater cognitive deficits. Thus, adverse
cognitive effects were detected 6 months following the acute treatment course.
Cognitive outcomes varied across treatment facilities and differences in ECT
technique largely accounted for these differences. Sine wave stimulation and BL
electrode placement resulted in more severe and persistent deficits.
PMID: 16936712 [PubMed – indexed for MEDLINE] 59. J ECT. 2006 Dec;22(4):267-70.

Electroconvulsive therapy in a pediatric patient with malignant catatonia and
paraneoplastic limbic encephalitis.

Lee A, Glick DB, Dinwiddie SH.

Department of Psychiatry, University of California at Los Angeles, Los Angeles,

Paraneoplastic limbic encephalitis is a rare disorder that can cause memory loss,
confusion, personality change, cognitive dysfunction, and psychosis. We present a
case of an 11-year-old girl who was successfully treated with electroconvulsive
therapy for a catatonic state associated with paraneoplastic limbic encephalitis
caused by an ovarian teratoma.
PMID: 17143159 [PubMed – indexed for MEDLINE] 60. J ECT. 2006 Dec;22(4):253-8.

Perspectives of patients and relatives about electroconvulsive therapy: a
qualitative study from Vellore, India.

Rajkumar AP, Saravanan B, Jacob KS.

Christian Medical College, Vellore, India.

BACKGROUND: There has been little systematic study from developing countries on
the perspectives of patients and their relatives about electroconvulsive therapy
(ECT). This study attempted to ascertain the views of patients and their
relatives on the possible benefits and adverse effects of ECT. METHOD:
Qualitative methodology using semistructured interviews, with the Short
Explanatory Model Interview as the basis, was used to interview 52 patients who
received ECT and their relatives before and after a course of the treatment. The
most eloquent 10 among them were chosen for further in-depth interviews.
Professional perception of efficacy and cognitive adverse effects were obtained
from the patients’ medical records. RESULTS: More than half of the recipients
were not aware of the details of ECT even at the end of the course but were not
unhappy about receiving ECT. Most relatives believed in the disease model,
considered the illness serious, felt that enough information about the treatment
was provided, knew about its benefits and memory problems, and felt that they
were offered an alternative choice of treatment, but also admitted to perceiving
coercion. All relatives had signed the consent for treatment, and most were not
unhappy with ECT. There were significant differences in perception between
patients and relatives and between the perceptions of patients admitted to the
hospital involuntarily and of those who agreed for admission. The difference
between the clinicians’ and the relatives’ perceptions of benefits and cognitive
adverse effects was not statistically significant. CONCLUSIONS: The results of
the study highlight the complex issues and contradictions in the process of
providing information and obtaining consent for ECT.
PMID: 17143156 [PubMed – indexed for MEDLINE] 61. Psychol Med. 2006 Dec;36(12):1799-809. Epub 2006 Aug 29.

Bipolar I and bipolar II disorder: cognition and emotion processing.

Summers M, Papadopoulou K, Bruno S, Cipolotti L, Ron MA.

NMR Research Unit, Institute of Neurology, University College London, London, UK.

BACKGROUND: Cognitive impairment may be part of the endophenotype of bipolar
disorder (BP), but little is known about patterns and severity of impairment in
BP subgroups and their relation to depression. The same applies to deficits in
emotion processing known to be present in BP. METHOD: To explore the relationship
between depression and impairment in cognition and emotion processing and the
differences between BP subgroups, we assessed 36 (25 BP I and 11 BP II) patients
using a cognitive battery and a facial emotion recognition task. RESULTS: BP
patients were impaired compared to published norms on memory, naming and
executive measures (Binomial Single Proportion tests, p<0.05). Cognitive
performance was largely unrelated to depression ratings. Surprise recognition was
the only emotion processing impairment in BP patients compared to controls
(patients’ recognition score 75% v. controls’ 89%, p=0.024). Patients with higher
depression ratings were more impaired in recognizing expressions of anger
(t23=2.21, p=0.037). BP II patients were more impaired than BP I patients in IQ,
memory and executive measures (Mann-Whitney tests, p<0.05). Depression severity
or exposure to medication or electroconvulsive therapy (ECT) did not explain
these differences. CONCLUSIONS: We confirm cognitive impairment and an isolated
facial emotion processing deficit in BP patients and suggest that these deficits
are largely unrelated to depressive symptoms. Our study also provides evidence
that cognitive deficits are more severe and pervasive in BP II patients,
suggesting that recurrent depressive episodes, rather than mania, may have a more
detrimental and lasting effect on cognition.
PMID: 16938147 [PubMed – indexed for MEDLINE] 62. MedGenMed. 2006 Sep 14;8(3):65.

Self management of fatal familial insomnia. Part 1: what is FFI?

Schenkein J, Montagna P.

Touro College, New York, NY, USA.

CONTEXT: Fatal familial insomnia (FFI) is a genetically transmitted
neurodegenerative prion disease that incurs great suffering and has neither a
treatment nor a cure. The clinical literature is devoid of management plans
(other than palliative). Part 1 of this article reviews the sparse literature
about FFI, including case descriptions. Part 2 of this paper describes the
efforts of 1 patient (with the rapid-course Met-Met subtype) to contend with his
devastating symptoms and improve the quality of his life. DESIGN: Interventions
were based on the premise that some symptoms may be secondary to insomnia and not
a direct result of the disease itself. Strategies (derived by trial and error)
were devised to induce sleep and increase alertness. Interventions included
vitamin supplementation, narcoleptics, anesthesia, stimulants, sensory
deprivation, exercise, light entrainment, growth hormone, and electroconvulsive
therapy. RESULTS: The patient exceeded the average survival time by nearly 1
year, and during this time (when most patients are totally incapacitated), he was
able to write a book and to successfully drive hundreds of miles. CONCLUSION:
Methods to induce sleep may extend and enhance life during the disease, although
they do not prevent death. It is hoped that some of his methods might inspire
further clinical studies.
PMCID: PMC1781306
PMID: 17406188 [PubMed – indexed for MEDLINE] 63. J ECT. 2006 Sep;22(3):206-12.

S100 and impact of ECT on depression and cognition.

Arts B, Peters M, Ponds R, Honig A, Menheere P, van Os J.

Department of Psychiatry and Neuropsychology, South Limburg Mental Health
Research and Teaching Network, EURON, Maastricht University, Maastricht, The

OBJECTIVES: The main side effects of electroconvulsive therapy (ECT) are in the
realm of cognition. The S100-beta is a calcium-binding protein that is expressed
by astrocytes in the central nervous system during depression and has been
suggested to modulate the impact of ECT on cognition. METHODS: Serum samples of
S100-beta were taken before and 1 and 3 hours after each ECT session in 12
depressed patients (mean age, 54 years), treated with bilateral ECT twice weekly
(mean, 6 sessions). Measures of depression (Symptom Checklist-90 depression
dimension) and a neurocognitive test battery yielding 3 domains of general
cognition, memory, and subjective cognitive impairment were administered 1 day
before and 5 and 30 days post-ECT. RESULTS: Electroconvulsive therapy was
associated with a reduction in depression and subjective cognitive impairment at
5 and 30 days post-ECT. Electroconvulsive therapy was associated with a small but
significant rise in S100-beta 1 hour post-ECT (adjusted B = 0.013, P = 0.035),
with a directionally similar but reduced effect size at 3 hours post-ECT
(adjusted B = 0.010, P = 0.10). Higher level of S100-beta at baseline was
associated with poorer memory function at 5 and 30 days of follow-up (adjusted B
per tertile group increase, 0.38, P = 0.013) but also with less subjective
cognitive impairment (B = -28.2, P < 0.001) and less depression at follow-up (B =
-15, P = 0.009). CONCLUSION: The S100-beta at baseline may be a marker predicting
and possibly mediating the differential impact of ECT on cognition and
PMID: 16957538 [PubMed – indexed for MEDLINE] 64. J ECT. 2006 Sep;22(3):199-205.

A retrospective controlled study into memory complaints reported by depressed
patients after treatment with electroconvulsive therapy and pharmacotherapy or
pharmacotherapy only.

Kho KH, VanVreeswijk MF, Murre JM.

GGZ Delfland St Jorisweg 2, 2612 GA Delft, the Netherlands.

Few studies have been conducted comparing complaints of memory problems using
objective and subjective memory scales in depressed patients who received
electroconvulsive therapy (ECT) + pharmacotherapy or treatment with
pharmacotherapy only. Patients who suffer from depression according to the
Diagnostic and Statistical Manual of Mental Disorder (Fourth Edition) criteria
and who were admitted within the past 5 years before this study in a general
psychiatric hospital were screened for inclusion. Objective retrograde amnesia
was assessed using the Autobiographical Memory Interview and the Amsterdam Media
Questionnaire (AMQ). Subjective retrograde amnesia was assessed using the Squire
Subjective Memory Questionnaire and the ECT Retrograde Amnesia and Perception
Scale (ERAPS), a newly developed scale. Twenty of the 84 patients who received
ECT + pharmacotherapy and 30 of the 196 patients who received pharmacotherapy
only participated in the study. Patients’ ERAPS memory scores were compared with
proxies’ ERAPS memory scores of the patients to assess the reliability of memory
complaints. The ECT + pharmacotherapy group was found to suffer more from memory
problems using the AMQ 1990 test. There was also a difference for the proxy’s
ERAPS memory score, reflecting the conviction of proxies from the ECT +
pharmacotherapy patients that these patients suffer more memory problems due to
the illness, treatment with pharmacotherapy, or ECT. The differences could not be
explained by the influence of determinants for retrograde amnesia. ECT +
pharmacotherapy patients did not attribute their memory problems mainly to ECT
but put equal “blame” on the depressive illness, treatment with pharmacotherapy,
and ECT. The analyses suggest that the AMQ 1990s test is (more) sensitive in
registering retrograde amnesia than the other scales used in the study.
PMID: 16957537 [PubMed – indexed for MEDLINE] 65. J ECT. 2006 Sep;22(3):189-95.

Memory performance in severely depressed patients treated by electroconvulsive

Hihn H, Baune BT, Michael N, Markowitsch H, Arolt V, Pfleiderer B.

Department of Clinical Radiology, University of Münster, Münster, Germany.

OBJECTIVES: Depression is accompanied by disturbed implicit (unconscious) and
explicit (conscious) memory functions. The aim was the assessment of immediate
and delayed verbal and visual memory functions, concentration/attention during
the course of electroconvulsive therapy (ECT) treatment. METHODS: Twenty severely
depressed, drug-treatment resistant, elderly patients were assessed with the
Wechsler Memory Scale-Revised (WMS-R) before and at the end of the ECT series.
RESULTS: Patients revealed deficits in acquisition (immediate verbal and visual
memory), attention/concentration, and retrieval of information (delayed memory)
before ECT. After ECT, significant improvements were observed in immediate memory
but not in delayed memory. Although higher total stimulation levels
(millicoulombs) (P = 0.015) were associated with improvements in immediate visual
memory, we found that longer duration of convulsions (P = 0.016) as well as lower
levels of stimulation at last ECT (P = 0.036) were associated with improvements
in immediate verbal memory. Moreover, we found that stimulation energy
(millicoulombs) in total and at last ECT was the best predictor among several
clinical and ECT parameters of improved visual memory and concentration and
decreased verbal and general memory. CONCLUSIONS: Prefrontal cortex-related
memory processes, especially immediate memory encoding, improved after ECT,
whereas long-term memory remained impaired, indicating that severely depressed
patients remain cognitively inferior to normal subjects despite clinically
successful treatment. This study may yield a better understanding of the time
course of memory alterations in severely depressed patients receiving ECT.
Improvement of immediate memory may be essential for establishing normal daily
activities of life in the recovery phase of depression.
PMID: 16957535 [PubMed – indexed for MEDLINE] 66. J ECT. 2006 Sep;22(3):163-8.

Therapeutic and prophylactic utility of the memory-enhancing drug donepezil
hydrochloride on cognition of patients undergoing electroconvulsive therapy: a
randomized controlled trial.

Prakash J, Kotwal A, Prabhu H.

Department of Psychiatry, Base Hospital, Delhi Cantt, New Delhi, India.

OBJECTIVES: Substantial progress has been made in identifying how the treatment
parameters used in electroconvulsive therapy (ECT) impact its cognitive side
effects. However, there is limited information regarding the role of memory
enhancers in post-ECT cognitive disturbances. We evaluated the therapeutic and
prophylactic efficacy of the memory-enhancing drug donepezil hydrochloride on
cognition of patients undergoing ECT. METHODS: A triple blind (the study
subjects, clinician assessing the cognition, and the data analyst were unaware of
subject allocation for trial assessment) randomized controlled trial was carried
out in a General Hospital Psychiatry Unit. Subjects were randomized into 2
groups. One group received ECT with placebo, whereas the other group received ECT
and donepezil (a memory-enhancing drug). Study participants were assessed in
post-ECT period to analyze cognitive deficits and to compare the differences in 2
groups, as regards recovery of various aspects of cognition. RESULTS: The
post-ECT recovery of various components of cognition was more rapid in patients
using donepezil as compared to those not given donepezil (P < 0.05). CONCLUSIONS:
This significant improvement in recovery time among patients receiving donepezil
bears therapeutic implication in immediate post-ECT cognitive deficits.
PMID: 16957530 [PubMed – indexed for MEDLINE] 67. N Z Med J. 2006 Jul 7;119(1237):U2051.

Electroconvulsive therapy in New Zealand: terrifying or electrifying?

Melding P.

Mental Health Services, Waitemata District Health Board, Takapuna, Auckland 1309.

Electroconvulsive therapy (ECT) is viewed by many patients as a ‘terrifying’
treatment. A petition to ban ECT presented to the House of Representatives in
1999 resulted in the commissioning of a comprehensive review of efficacy and
safety of the treatment in New Zealand as well as a requirement for the Ministry
of Health (MOH) to collect annual statistics on ECT use. Although the systematic
review found that ECT was a safe and effective treatment for depression and some
other serious mental illnesses, it still attracted adverse comments from
opponents. Almost immediately following its publication, another petition was
presented to Parliament, this time requesting that ECT be banned for young
people, pregnant women, and older people. Compared to similar countries, New
Zealand has a low rate of use for ECT overall, with wide regional variance. There
are many misconceptions about ECT in New Zealand that are not in keeping with
current standards of practice and may be limiting its use in some areas. However,
access to resources for the treatment of depression may be a major limiting
factor. ‘Electrifying’ new research emanating from neurobiological and magnetic
resonance imaging (MRI) studies is challenging traditional notions of depression,
and is providing more explanations on how ECT and other antidepressant treatments
might work. These new findings demonstrate that cognitive deficits and structural
brain changes play important roles in serious depression and suggest that early
and adequate treatment of major depression should be paramount.
PMID: 16862197 [PubMed – indexed for MEDLINE] 68. J ECT. 2006 Jun;22(2):107-12.

Memory, attention, and executive functions before and after sine and pulse wave
electroconvulsive therapies for treatment-resistant major depression.

Fujita A, Nakaaki S, Segawa K, Azuma H, Sato K, Arahata K, Otsuki K, Hori M,
Mochida Y, Uchida M, Yamada T, Nakamura C, Akechi T, Furukawa TA.

Department of Psychiatry and Cognitive-Behavioral Medicine, Nagoya City
University Graduate School of Medical Sciences, Nagoya, Japan.

OBJECTIVE: Studies of the cognitive effects of electroconvulsive therapy (ECT)
have resulted in controversial findings up to now, partly because researchers and
reviewers have not always made a clear distinction among various aspects of
cognition and because there are many parameters involved in the administration of
ECT that have a potential impact on cognition. The present study focused on the
impact of sine and pulse waveforms on anterograde memory and nonmemory cognitive
functions. METHODS: We assigned 18 patients with unipolar major depression or
bipolar I or II disorder, most recent episode depressed, to receive sine wave or
pulse wave ECT and assessed their cognitive function before and after ECT, using
a neuropsychologic test battery that measured anterograde memory, attention, and
executive functions. Outcomes were measured, on average, 8.2 days after the last
ECT session. RESULTS: Both waveforms were equally effective in alleviating
depression. Those who received sine wave ECT showed statistically significant
deterioration in attention and executive tasks, such as the Stroop test, which
measures selective attention (P = 0.02), and the dual task, which taps divided
attention (P = 0.01). On the other hand, those who received pulse wave ECT
improved to a significant degree in certain memory tasks, such as visual memory
(P = 0.01) and general memory (P = 0.01) of the Wechsler Memory Scale-Revised
(WMS-R), as well as in the dual task (P = 0.01). The between-group comparison
revealed robust superiority of the pulse wave over the sine wave in terms of the
dual task (P = 0.004). CONCLUSIONS: Anterograde memory improved to a
statistically significant or nonsignificant degree at 1 week post-ECT in
comparison with pre-ECT regardless of waveforms. Attention/executive functions
tended to deteriorate with sine wave ECT but improved with pulse wave ECT.
PMID: 16801825 [PubMed – indexed for MEDLINE] 69. J ECT. 2006 Jun;22(2):103-6.

Ketamine appears associated with better word recall than etomidate after a course
of 6 electroconvulsive therapies.

McDaniel WW, Sahota AK, Vyas BV, Laguerta N, Hategan L, Oswald J.

Department of Psychiatry and Behavioral Science, Eastern Virginia Medical School,
825 Fairfax Avenue, Norfolk, VA 23507, USA. mcdaniww@EVMS.EDU

Ten patients treated with electroconvulsive therapy (ECT) for depressive illness
received anesthesia with either etomidate or ketamine. Three patients received
both etomidate and ketamine anesthesia for ECT during separate episodes of
depression. Patients anesthetized with ketamine for ECT had significantly less
impairment of short-term memory function than did patients who received ECT with
etomidate anesthesia. All patients who received both anesthetics for ECT during 2
different episodes had less memory loss during ECT with ketamine than with
etomidate. These results show the importance of studying the effects of all
anesthetic agents used during ECT on cognitive functions. The results imply that
the effect of ECT on memory may be largely caused by effects mediated by
glutamate at N-methyl-d-aspartate receptors and suggest that N-methyl-d-aspartate
antagonists may offer protection from memory dysfunction during ECT.
PMID: 16801824 [PubMed – indexed for MEDLINE] 70. Wien Med Wochenschr. 2006 Apr;156(7-8):200-8.

[Adverse cognitive effects and ECT] [Article in German]

Prapotnik M, Pycha R, Nemes C, König P, Hausmann A, Conca A.

Abteilung für Psychiatrie I, LKH Rankweil, Austria.

Electroconvulsive therapy (ECT) is a rapidly acting and highly effective
treatment for severe and life threatening conditions seen in affective and
schizophrenic diseases. Notwithstanding its therapeutic benefits, ECT remains
controversial because of seizure induction, cognitive side effects, memory
dysfunction and effects on cerebral physiology. These factors have raised the
concern that ECT produces structural and functional brain damages. This issue
continues to have a major impact on the acceptance of ECT as a therapeutic
modality, both within the medical community and in public opinion. A close look
at incidence, type, severity, neurofunctional and -anatomical correlates,
aetiology and therapeutic approaches of the adverse cognitive effects attributed
to ECT may contribute to rational and objective handling of this topic. The final
chapter deals with the issue of whether ECT causes brain damage.
PMID: 16823537 [PubMed – indexed for MEDLINE] 71. J ECT. 2006 Mar;22(1):67-9.

Acute embolic stroke after electroconvulsive therapy.

Lee K.

Vascular and Critical Care Neurology, Massachusetts General Hospital, Harvard
Medical School, Boston, USA.

Erratum in:
J ECT. 2006 Dec;22(4):280.

This is the case report of a 44-year-old woman presented with an acute stroke
immediately after electroconvulsive therapy (ECT). The patient had no significant
medical history other than chronic depression. She was taking sertraline, and she
had had multiple previous ECT treatments without any complications. While being
monitored in the recovery room within 10 minutes after the last ECT session, she
was found to have sudden onset of left-sided flaccid hemiplegia and numbness
along with slurred speech. On arrival to our hospital, she was found to have
flaccid hemiplegia on the left side involving the face, arm, and leg (face and
arm more than the leg involvement), severe dysarthria, and mild neglect syndrome
(National Health Institute Stroke Scale of 14). Noncontrast computed tomography
(CT) of the head showed no signs of early ischemia, and iodine contrast CT
angiography revealed right middle cerebral artery (MCA) (distal M1 segment) clot.
Patient received intravenous recombinant tissue plasminogen (rt-PA) at 2.5 hours
after the onset of symptoms, and then a total of 3.0 mg of intra-arterial (IA)
rt-PA. Angiography at the end of the procedure showed successful recanalization
of the M1 segment and normal vessel caliber with adequate distal flow. After the
procedure, the patient made rapid improvements in all of her initial symptoms
during the first 24 hours. An extensive stroke workup failed to reveal any cause
of the stroke, including usual stroke and hypercoagulable risk factors. This was
an acute embolic stroke immediately following an ECT, and without the aggressive
thrombolytic therapy, the patient’s outcome would have been poor because there
was an M1 segment clot with a major MCA syndrome with relatively high National
Institute of Health Stroke Scale. The neurological side effect profile of ECT is
reported to be minimal with most common symptoms being headache, disorientation,
and memory complaints. There is no clear cause-and-effect relationship in this
case, and the stroke after ECT is extremely rare. In such rare event of stroke
while receiving ECT, there is an effective treatment available using both
intravenous and IA thrombolysis as reported in this case.
PMID: 16633211 [PubMed – indexed for MEDLINE] 72. J ECT. 2006 Mar;22(1):43-5.

Clinical outcome and memory function with maintenance electroconvulsive therapy:
a retrospective study.

Abraham G, Milev R, Delva N, Zaheer J.

Centre for Addiction and Mental Health, West, Toronto, Ontario, Canada.

Although maintenance electroconvulsive therapy (ECT) appears to be the logical
choice for the prevention of relapses and recurrences in patients with refractory
depression who have responded to a course of ECT, the perception of ECT’s
negative effect on memory continues to limit its wider use. This retrospective
study of depressed patients maintained on ECT after an initial course revealed
that maintenance ECT was effective in sustaining clinical improvement,
particularly in patients who showed a satisfactory clinical response to the
initial course of ECT, and that memory difficulties were limited and tolerable.
PMID: 16633206 [PubMed – indexed for MEDLINE] 73. J Geriatr Psychiatry Neurol. 2006 Mar;19(1):21-5.

Hippocampal volume is associated with physician-reported acute cognitive deficits
after electroconvulsive therapy.

Lekwauwa R, McQuoid D, Steffens DC.

Department of Psychiatry and Behavioral Sciences, Duke University Medical Center,
Durham, North Carolina 27710, USA.

Predicting memory problems in older depressed patients receiving
electroconvulsive therapy (ECT) is difficult. In this study, hippocampal volume
and acute memory outcomes were examined in 15 patients following an index course
of ECT. Smaller hippocampal volume was associated with poorer ECT-related memory
outcomes. These results add to a growing literature on memory, ECT, and the
hippocampus. Although the findings are significant, the sample size in the study
is small, so future studies with more complex modeling of key variables that may
influence memory are warranted.
PMID: 16449756 [PubMed – indexed for MEDLINE] 74. Clin Neuropharmacol. 2006 Jan-Feb;29(1):52-6.

Concurrent administration of clozapine and electroconvulsive therapy in
clozapine-resistant schizophrenia.

Havaki-Kontaxaki BJ, Ferentinos PP, Kontaxakis VP, Paplos KG, Soldatos CR.

Department of Psychiatry, Eginition Hospital, University of Athens, Athens,

OBJECTIVE: The aim of this article is to critically review all published studies
regarding the efficacy and safety of the concurrent administration of clozapine
(CLZ) and electroconvulsive therapy (ECT) in CLZ-resistant schizophrenic or
schizoaffective patients. METHOD: A MEDLINE search from January 1980 to July 2005
was conducted. RESULTS: One open-label trial and 6 case studies were located,
comprising 21 schizophrenic and 1 schizo affective patients (12 men and 10 women)
with a mean age of 41.9 years. The duration and dosage of CLZ monotherapy before
ECT were reported at least 12 weeks and 300 mg/d, respectively, in 10 patients
(45.4%). Plasma CLZ levels before ECT were assessed in 12 patients (54.5%), in
which only 7 (31.8%) were reported to be higher than 350 ng/mL. The CLZ dosage
during ECT ranged from 200 to 900 mg/d (mean, 518.2 +/- 203.3 mg/d). The number
of ECT sessions ranged from 2 to 20 (mean, 11.5 +/- 5.4). Application of
electrodes was unilateral in 7 patients, bilateral in 10 patients, and mixed in 2
patients. Sixteen patients (72.7%) showed marked improvement whereas 6 patients
(27.3%) had moderate, minimal, or no improvement. No predictors of outcome could
be isolated. Side effects reported by 5 patients (22.7%) were nausea,
tachycardia, hypertension, memory problems, and confusion. Ten patients (45.4%)
relapsed during follow-up. Substantial improvement persisted beyond 4 months in
only 5 patients (22.7%). CONCLUSION: Preliminary evidence exists for the safety
and short-term efficacy of the concurrent administration of CLZ and ECT in
CLZ-resistant schizophrenic or schizoaffective patients.
PMID: 16518135 [PubMed – indexed for MEDLINE] 75. Depress Anxiety. 2006;23(2):93-101.

Age-related cognitive effects of ECT and ECT-induced mood improvement in
depressive patients.

Bosboom PR, Deijen JB.

Department of Clinical Neuropsychology, Vrije Universiteit, Amsterdam, The

This explorative study investigated the interaction between electroconvulsive
therapy (ECT) treatment-effect, reduced depression, and neuropsychological
outcome in relation to age. Follow-up neuropsychological assessment was conducted
with depressive patients treated with ECT. From a potential sample of 45
patients, the neuropsychological measures (pre-ECT, three times post-ECT, up to
12 months) and clinical data from the remaining 21 patients who completed all
assessments were evaluated (mean age=56.76; SD=14.12; range, 33-79). ECT resulted
in a decrease in the depression scores. A distinct impact of ECT and depression
decrease on cognitive domains was found. Depression alleviation was mainly
associated with improvement in cognitive domains such as memory, information
processing, and executive function. ECT improved cognitive domains such as
information processing and perception. Short-term cognitive improvement was
greater in older patients but showed an increase similar to that at long-term
follow-up in younger patients (<60). Current findings provide evidence that ECT
may improve cognitive functioning in nondemented elderly, which has strong
clinical relevance concerning the use of ECT.
PMID: 16400627 [PubMed – indexed for MEDLINE] 76. J ECT. 2005 Dec;21(4):227-31.

Patient satisfaction after electroconvulsive therapy.

Sienaert P, De Becker T, Vansteelandt K, Demyttenaere K, Peuskens J.

ECT Department, University Center Sint-Jozef, Katholieke Universiteit Leuven,
Leuvensesteenweg Kortenberg, Belgium.

OBJECTIVE: We sought to determine the degree of satisfaction with bifrontal and
right unilateral electroconvulsive therapy (ECT) and to investigate the relation
with treatment-related variables, such as memory complaints, and patient-related
variables, such as self-rated depression severity and negative affectivity.
METHODS: Subjects included all patients who started a course of ECT between May
2001 and December 2003, or still were receiving continuation or maintenance ECT
(C/M-ECT) at the time of the study. A psychiatric nurse that was not a member of
the treatment team conducted semi-structured interviews based on a battery of
questionnaires (Patient Satisfaction Survey [PSS], Mini-Mental State Examination
[MMSE], Squire Subjective Memory Questionnaire [SSMQ], Beck Depression Inventory
[BDI], and Positive and Negative Affect Schedule [PANAS]). RESULTS: Of 50
eligible subjects, 36 (72%) completed the survey. Fourteen patients refused to
participate. At the time of the interview, 19 patients (52.8%) were hospitalized,
and 14 (38.9%) were receiving C/M-ECT. The mean time between last treatment
session and interview was 282 days. Diagnostic categories were depressive
disorder (50%) and psychotic disorder (47.2%). Bifrontal electrode position was
used in 25 (69.4%) of the study patients and unilateral in 4 (11.1%). Patients
had a considerable degree of satisfaction (mean PSS 153.41; SD 16.29), although
they had prominent cognitive complaints (mean score SSMQ -11.86; SD 21.30). In a
multiple regression model, in which satisfaction was predicted on the basis of
age, sex, and scores on BDI, SSMQ, PANAS, and GAF, only the GAF-score at the time
of the interview was significantly related to satisfaction. All other predictors
were not significant. CONCLUSION: Patients receiving bifrontal or right
unilateral ECT do have considerable memory complaints, even a long time after
their treatment. However, the degree of these complaints does not seem to predict
satisfaction with the treatment. Only 38% of the variance of satisfaction could
be predicted on the basis of age, sex, BDI, SSMQ, Negative Affectivity subscale
of the PANAS, and GAF-scores, which proves that satisfaction with ECT is based on
other factors than just the relief of symptoms or the occurrence of side-effects.
The factors that contribute to patients’ satisfaction remain largely unknown.
PMID: 16301882 [PubMed – indexed for MEDLINE] 77. J ECT. 2005 Dec;21(4):214-20.

Long-term follow-up in depressed patients treated with electroconvulsive therapy.

Johanson A, Gustafson L, Risberg J, Rosén I, Sjöbeck M, Silfverskiöld P.

Department of Psychogeriatrics, Lund University, Lund, Sweden.

DESIGN: Our aim was to study the long-term effects of electroconvulsive therapy
(ECT) in depression. A total of 55 patients were followed-up 20 to 24 years after
an ECT series; 13 patients were still alive, and 10 agreed to participate in the
study. All 55 patients had been investigated with clinical and neuropsychological
assessment and with neurophysiological measurements and with regional cerebral
blood flow (rCBF) and EEG before the first ECT, 6 months later, and after
approximately 1 year. These investigations were repeated in the 10 patients.
RESULTS: Before the original ECT series, all patients had suffered from severe
mood disorder. At follow-up, the 10 patients showed no clear signs of mood
disorder or cognitive impairment. There was a slightly subnormal performance in
working memory and in verbal as well as visual episodic memory on all 3 occasions
after the ECT series. The rCBF measurement showed a significant average CBF
decrease from the first to the last measurement. There was, moreover, a
significant rCBF decrease in frontal areas at the last measurement compared with
the 3 previous assessments. CONCLUSION: All ten patients followed-up 20 to 24
years after an ECT series were mentally healthy and thus besides a moderate
visual memory dysfunction, no severe side effects were observed with clinical and
neuroimaging techniques.
PMID: 16301880 [PubMed – indexed for MEDLINE] 78. Psychiatr Prax. 2005 Nov;32(8):408-11.

[Continuation ECT] [Article in German]

Sartorius A, Henn FA.

Zentralinstitut für Seelische Gesundheit, Mannheim.

A renaissance of electroconvulsive therapy in psychiatry can be observed in
Germany. Here, ECT was named as a first line therapy for treating psychotic
depression, depressive stupor, schizoaffective psychoses with severe depressive
symptoms. Suprisingly, ECT is most commonly not used as a continuation therapy
after achieving acute remission. With rare exceptions, antidepressive medication
is chosen for this purpose. The use of continuation ECT (cECT) and subsequent
maintenance ECT (mECT) is not (or just marginally) mentioned in practice
guidelines. In our case report we report a successful cECT and mECT of a
geriatric patient with severe comorbidity. This case is exemplified with respect
to recent guidelines and study results. Particularly suggestions for interval
duration, total duration of treatment, effects on cognition and memory,
comorbidity and comedication, and reflections on quality of life and costs were
discussed. We would therefore recommend a broader use of this proven treatment
tool for keeping major depressions in remission.
PMID: 16308805 [PubMed – indexed for MEDLINE] 79. Cogn Behav Neurol. 2005 Sep;18(3):141-3.

Catatonia causing permanent cognitive impairment: a case study.

Baker IW, Jackson M, Bass C.

Russell Cairns Unit, Radcliffe Infirmary, Oxford, OX2 6HE, England.

OBJECTIVE: We describe a case of psychogenic malignant catatonia resulting in
permanent cognitive impairment. BACKGROUND: Catatonia is a neuropsychiatric
syndrome characterized by catalepsy, negativism, mutism, muscular rigidity, and
mannerisms, often accompanied by autonomic instability and fever. Little is known
about the long-term cognitive consequences of the syndrome. METHOD: Medical
history includes neurologic examination, neuropsychological evaluation,
electroencephalographic data, magnetic resonance imaging, sodium amytal
interview, and treatment with electroconvulsive therapy. RESULTS: Selective
deficits in executive function and an anterograde amnesia were evident a week
post-ECT treatment and continued to be present at follow-up after 2 years and 8
months. CONCLUSION: The permanent cognitive impairments are considered in the
context of catatonia as a frontal lobe syndrome.
PMID: 16175016 [PubMed – indexed for MEDLINE] 80. Int J Geriatr Psychiatry. 2005 Aug;20(8):790-5.

Neuropsychological prediction of recovery in late-onset major depression.

Marcos T, Portella MJ, Navarro V, Gastó C, Rami L, Lázaro L, Salamero M.

Clinical Psychology Department, Institut Clínic de Psiquiatría y Psicología,
Hospital Clínic de Barcelona, Barcelona, Spain.

OBJECTIVES: To assess antidepressant response in late-onset major depression in
relation to neuropsychological domains: attention, memory and planning. METHODS:
A neuropsychological battery was administered in 30 medication-free patients with
late-onset major depression, who were then included in a 12-week antidepressant
treatment regimen within a 12-month follow-up period. Logistic regression was
used to define a predictive model of recovery. RESULTS: Eighteen patients were
classed as remitters and seven as non-remitters. The ‘indexrem’ refers to the
results of a logistic regression from verbal learning and planning and had a
global predictive power of 84%. CONCLUSIONS: Our study suggests that the balance
between verbal learning (memory) and planning (executive function)-both related
to the dorsolateral prefrontal cortex-could predicts recovery.
PMID: 16035125 [PubMed – indexed for MEDLINE] 81. Br J Psychiatry. 2005 May;186:410-6.

Distinctive neurocognitive effects of repetitive transcranial magnetic
stimulation and electroconvulsive therapy in major depression.

Schulze-Rauschenbach SC, Harms U, Schlaepfer TE, Maier W, Falkai P, Wagner M.

Department of Psychiatry, University of Bonn, Sigmund-Freud-Str. 25, D 53105
Bonn, Germany.

Comment in:
Br J Psychiatry. 2005 Nov;187:487; author reply 488.
Br J Psychiatry. 2005 Nov;187:487-8; author reply 488.
Br J Psychiatry. 2005 Oct;187:386; author reply 386-7.

BACKGROUND: Studies have compared electroconvulsive therapy (ECT) and repetitive
transcranial magnetic stimulation (rTMS) with regard to clinical efficacy in the
treatment of depression, but no study has yet addressed the differential impact
on cognition. AIMS: To compare the neurocognitive effects of unilateral ECT and
rTMS. METHOD: Thirty patients with treatment-refractory non-psychotic major
depression received an average of ten treatments with either unilateral ECT or
left prefrontal rTMS and were assessed for objective and subjective cognitive
impairments before and about a week after treatment. RESULTS: Treatment response
was comparable (46% of the ECT group and 44% of the rTMS group showed a reduction
of 50% or more in Hamilton Rating Scale for Depression scores). In patients
treated with rTMS, cognitive performance remained constant or improved and memory
complaints alleviated, whereas in the ECT group memory recall deficits emerged
and memory complaints remained. CONCLUSIONS: In contrast to unilateral ECT, rTMS
has no adverse memory effects.
PMID: 15863746 [PubMed – indexed for MEDLINE] 82. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD000076.

Electroconvulsive therapy for schizophrenia.

Tharyan P, Adams CE.

Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India,

Update of:
Cochrane Database Syst Rev. 2002;(2):CD000076.

BACKGROUND: Electroconvulsive therapy (ECT) involves the induction of a seizure
for therapeutic purposes by the administration of a variable frequency electrical
stimulus shock via electrodes applied to the scalp. The effects of its use in
people with schizophrenia are unclear. OBJECTIVES: To determine whether
electroconvulsive therapy (ECT) results in clinically meaningful benefit with
regard to global improvement, hospitalisation, changes in mental state, behaviour
and functioning for people with schizophrenia, and to determine whether
variations in the practical administration of ECT influences outcome. SEARCH
STRATEGY: We undertook electronic searches of Biological Abstracts (1982-1996),
EMBASE (1980-1996), MEDLINE (1966-2004), PsycLIT (1974-1996),SCISEARCH (1996) and
the Cochrane Schizophrenia Group’s Register (July 2004). We also inspected the
references of all identified studies and contacted relevant authors. SELECTION
CRITERIA: We included all randomised controlled clinical trials that compared ECT
with placebo, ‘sham ECT’, non-pharmacological interventions and antipsychotics
and different schedules and methods of administration of ECT for people with
schizophrenia, schizoaffective disorder or chronic mental disorder. DATA
COLLECTION AND ANALYSIS: Working independently, we selected and critically
appraised studies, extracted data and analysed on an intention-to-treat basis.
Where possible and appropriate we calculated risk ratios (RR) and their 95%
confidence intervals (CI) with the number needed to treat (NNT). For continuous
data Weighted Mean Differences (WMD) were calculated. We presented scale data for
only those tools that had attained pre-specified levels of quality. We also
undertook tests for heterogeneity and publication bias. MAIN RESULTS: This review
includes 26 trials with 50 reports. When ECT is compared with placebo or sham
ECT, more people improved in the real ECT group (n=392, 10 RCTs, RR 0.76 random
CI 0.59 to 0.98, NNT 6 CI 4 to 12) and though data were heterogeneous (chi-square
17.49 df=9 P=0.04), its impact on variability of data was not substantial
(I-squared 48.5%). There was a suggestion that ECT resulted in less relapses in
the short term than sham ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a
greater likelihood of being discharged from hospital (n=98, 1 RCT, RR fixed 0.59,
CI 0.34 to 1.01). There is no evidence that this early advantage for ECT is
maintained over the medium to long term. People treated with ECT did not drop out
of treatment earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed
0.71 CI 0.33 to 1.52, I-squared 0%). Very limited data indicated that visual
memory might decline after ECT compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI
-23 to -5); the results of verbal memory tests were equivocal. When ECT is
directly compared with antipsychotic drug treatments (total n=443, 10 RCTs)
results favour the medication group (n=175, 3 RCTs, RR fixed ‘not improved at the
end of ECT course’ 2.18 CI 1.31 to 3.63). Limited evidence suggests that ECT
combined with antipsychotic drugs results in greater improvement in mental state
(n= 40, 1 RCT, WMD, Brief Psychiatric Rating Scale -3.9 CI – 2.28 to -5.52) than
with antipsychotic drugs alone. One small study suggested more memory impairment
after a course of ECT combined with antipsychotics than with antipsychotics alone
(n=20, MD serial numbers and picture recall -4.90 CI -0.78 to -9.02), though this
proved transient. When continuation ECT was added to antipsychotic drugs, the
combination was superior to the use of antipsychotics alone (n=30, WMD Global
Assessment of Functioning 19.06 CI 9.65 to 28.47), or CECT alone (n=30, WMD
-20.30 CI -11.48 to -29.12). Unilateral and bilateral ECT were equally effective
in terms of global improvement (n=78, 2 RCTs, RR fixed ‘not improved at end of
course of ECT’ 0.79 CI 0.45 to 1.39). One trial showed a significant advantage
for 20 treatments over 12 treatments for numbers globally improved at the end of
the ECT course (n=43, RR fixed 2.53 CI 1.13 to 5.66). AUTHORS’ CONCLUSIONS: The
evidence in this review suggests that ECT, combined with treatment with
antipsychotic drugs, may be considered an option for people with schizophrenia,
particularly when rapid global improvement and reduction of symptoms is desired.
This is also the case for those with schizophrenia who show limited response to
medication alone. Even though this initial beneficial effect may not last beyond
the short term, there is no clear evidence to refute its use for people with
schizophrenia. The research base for the use of ECT in people with schizophrenia
continues to expand, but even after more than five decades of clinical use, there
remain many unanswered questions regarding its role in the management of people
with schizophrenia.
PMID: 15846598 [PubMed – indexed for MEDLINE] 83. Acta Neurobiol Exp (Wars). 2005;65(1):73-7.

Does electroconvulsive therapy (ECT) affect cognitive components of auditory
evoked P300?

Griskova I, Dapsys K, Andruskevicius S, Ruksenas O.

Department of Biochemistry and Biophysics, Vilnius University, Ciurlionio-21,
Vilnius, LT-03101 Lithuania.

Electroconvulsive therapy (ECT), as a treatment tool for psychiatric disorders,
is believed to be safe and effective. Nevertheless, it has a negative impact on
cognitive functioning, especially on memory, causing both retrograde and
anterograde amnesia. However, ECT effects on more subtle stages of information
processing are not studied enough. Event-related potentials, and especially P300,
are thought to reflect physiology of cognition. Thus, we aimed to evaluate the
effects of ECT treatment on parameters of endogenous components (N2, P3) of the
P300 potential. Seventeen patients suffering from schizophrenia, schizoaffective
disorder and recurrent depressive disorder participated at the study. After the
course of ECT, significant increase of N2 amplitude in parietal midline region
and prolongation of P3 latency in frontal midline region, of which the magnitude
positively correlated with the number of ECT procedures, have been obtained.
PMID: 15794033 [PubMed – indexed for MEDLINE] 84. Neuropsychobiology. 2005;52(4):183-9. Epub 2005 Oct 10.

Interictal slow-wave focus in left medial temporal lobe during bilateral
electroconvulsive therapy.

Neuhaus AH, Gallinat J, Bajbouj M, Reischies FM.

Department of Psychiatry and Psychotherapy, Charité University Medicine Berlin,
Campus Benjamin Franklin, Berlin, Germany.

The interictal state between two electroconvulsive therapy (ECT) sessions is
clinically characterised by possible cognitive adverse effects like mild amnestic
syndrome. ECT-induced amnestic deficits can persist for several weeks after ECT.
Electrophysiologically, slowing of brain electrical activity in the interictal
state has often been reported. Especially, for bilateral ECT a correlation
between enhanced left frontotemporal theta activity and retrograde amnesia has
been demonstrated. This study focuses on the topographic distribution of cortical
slow-wave oscillations during the interictal state of a bilateral ECT cycle.
Twelve patients with major depression have been investigated with 32-channel
resting EEG 24 h after the 6th ECT session. As controls, 8 major depressive
patients were investigated prior to antidepressive treatment. The generating
sources of slow-wave activity are estimated within the theta frequency band with
low-resolution brain electromagnetic tomography. Source analysis revealed a
distinct pattern of theta activity in the depth of the left temporal lobe
(fusiform and parahippocampal gyri, Brodmann areas 37 and 36, respectively; p<
0.05) during the interictal state. This finding suggests a dysfunction of the
left medial temporal lobe memory system during the interictal state of a
bilateral ECT cycle. It will further be discussed whether it is possible to
obtain information about activity of deep brain structures like the hippocampal
formation from scalp-recorded signals.
PMID: 16220024 [PubMed – indexed for MEDLINE] 85. J Affect Disord. 2004 Nov 1;82(3):335-42.

Electroconvulsive therapy in adolescent and adult psychiatric inpatients–a
retrospective chart design.

Stein D, Kurtsman L, Stier S, Remnik Y, Meged S, Weizman A.

The Chaim Sheba Medical Center, Tel Hashomer, Israel.

BACKGROUND: The knowledge available on electroconvulsive therapy (ECT) in
adolescents is largely anecdotal, or based on findings from adults. The aim of
the present study is to compare the use of ECT in adolescent and adult
inpatients. METHODS: We retrospectively analyzed the files of all 36 adolescent
(between the ages of 13 and 19) and 57 randomly selected adult inpatients (above
the age of 20) treated with ECT in a university-affiliated mental heath center in
Israel between 1991 and 1997. RESULTS: Sixty one percent of the adolescents
improved by the end of treatment, and 53% were not hospitalized in the subsequent
year. The respective percentages among adults were 83% and 49%. Whereas most
adults were treated with ECT because of schizophrenic disorders, almost half of
the adolescents received ECT for affective disorders. Significantly more
adolescents were treated with ECT because of acute life-endangering conditions
(catatonia or severe suicidal risk). No significant adverse effects were found in
both groups. LIMITATIONS: Our study is based on a retrospective chart review. The
adolescent and adult groups are different in psychiatric morbidity, diagnosis and
outcome, have not been assessed in a blind manner, and we have not used
standardized psychometric batteries for the evaluation of ECT-related memory
disturbances. CONCLUSIONS: ECT may be an effective, well-tolerated and safe
procedure in both adult and adolescent inpatients.
PMID: 15555684 [PubMed – indexed for MEDLINE] 86. J Neuropsychiatry Clin Neurosci. 2004 Fall;16(4):465-71.

Cognitive status of psychiatric patients under maintenance electroconvulsive
therapy: a one-year longitudinal study.

Rami L, Bernardo M, Boget T, Ferrer J, Portella MJ, Gil-Verona JA, Salamero M.

Clinic Institute of Psychiatry and Psychology, Hospital Clinic, Barcelona, Spain.

In recent years, maintenance electroconvulsive therapy (M-ECT) has been a common
treatment within psychiatric practice. Little information is available regarding
the cognitive risks of this treatment, however. In this study, twenty psychiatric
outpatients were assessed during M-ECT and 1 year later on treatment. A
comprehensive cognitive battery was administered, and a separate comparison group
was used to calculate the Reliable Change Index. Global cognitive measures showed
no significant difference in scores over time. Our results concur with those
described in case reports and suggest that there is no significant association
between cognitive decline and M-ECT.
PMID: 15616173 [PubMed – indexed for MEDLINE] 87. Int J Geriatr Psychiatry. 2004 Sep;19(9):833-42.

Antidepressant efficacy and cognitive effects of repetitive transcranial magnetic
stimulation in vascular depression: an open trial.

Fabre I, Galinowski A, Oppenheim C, Gallarda T, Meder JF, De Montigny C, Olié JP,
Poirier MF.

Sainte-Anne Hospital, University Department of Psychiatry, Paris, France.

BACKGROUND: Beneficial effects of repetitive transcranial magnetic stimulation
(rTMS) were demonstrated by many controlled studies in major depression.
Moreover, this promising and non invasive therapeutic tool seems to be better
tolerated than electroconvulsive therapy.Vascular depression is a subtype of
late-life depression, associated with cerebrovascular disease and means a poorer
response to antidepressant treatment. We employed rTMS over the left prefrontal
cortex in 11 patients with late-onset resistant vascular depression. The primary
purpose of this two-week open study was to examine antidepressant efficacy of
rTMS in vascular depression. The secondary aim was to evaluate cognitive effects
of rTMS in our sample. METHODS: Clinical status, as measured with the Hamilton
Depression Rating Scale (HDRS), and cognitive effects, as evaluated by
neuropsychological tests, were assessed at baseline and after two weeks of rTMS.
Brain measurements to obtain an index of prefrontal atrophy were performed at
both the motor cortex and prefrontal cortex. RESULTS: Five out of 11 resistant
patients with late-onset vascular depression were responders. They showed a
clinically meaningful improvement in HDRS scores, with a decrease of 11, 4 points
(p<0.01). Antidepressant response is correlated to the relative degree of
prefrontal atrophy (p = 0.05). After two weeks, verbal fluency and visuospatial
memory improved. No cognitive performance deteriorated except for verbal memory,
as the delayed recall decreased significantly in the responders’ group.
CONCLUSIONS: Our preliminary observations prompt to perform a subsequent
controlled study to examine if rTMS may constitute an alternative to
electroconvulsive therapy.
PMID: 15352140 [PubMed – indexed for MEDLINE] 88. J ECT. 2004 Sep;20(3):145-53.

Comparison of clinical efficacy and side effects for bitemporal and bifrontal
electrode placement in electroconvulsive therapy.

Bakewell CJ, Russo J, Tanner C, Avery DH, Neumaier JF.

University of Washington School of Medicine, Seattle, USA.

OBJECTIVES: Bifrontal (BF) placement of electrodes in electroconvulsive therapy
(ECT) has become a popular alternative to bitemporal (BT) placement. This study
compares the clinical efficacy, side effects, and rehospitalization rates of BT
and BF electrode placement in a community hospital setting. METHODS: Charts from
76 patients receiving ECT treatments at Harborview Medical Center from 1994 to
2000 were reviewed to extract data on the characteristics of the course of ECT,
clinical response, total headaches, narcotic and nonsteroidal anti-inflammatory
drug doses, as well as documentation of confusion, disorientation, memory loss,
and treatment emergent need for assistance with activities of daily living.
RESULTS: The BT patients experienced more clinical improvement during their stay
(a 7-point greater change in Psychiatric Symptom Assessment Scale score, P <
0.05) and were significantly less likely to be rehospitalized within a 1-year
time frame (odds ratio = 4.9, P = <0.05), even after controlling for relevant
covariates. Although the two patient groups had equal rates of headache and
analgesic administration, the BT placement caused significantly more cognitive
impairment. CONCLUSIONS: This study suggests that BT electrode placement offers
better efficacy but modestly greater cognitive impairment than BF electrode
PMID: 15342998 [PubMed – indexed for MEDLINE] 89. J ECT. 2004 Mar;20(1):26-36.

A primate model of anterograde and retrograde amnesia produced by convulsive

Moscrip TD, Terrace HS, Sackeim HA, Lisanby SH.

Department of Biological Psychiatry, New York State Psychiatric Institute, New
York, New York, USA.

A nonhuman primate model of the key cognitive effects of convulsive treatment was
developed and tested. Rhesus macaques were trained on 3 tasks: a long-term memory
task that required selection of a constant target from a background of
distracters, an anterograde task that involved learning a new target each day
against a variable number of distracters, and a task that assessed learning and
memory for new and previously trained 3-item serial lists. This battery samples a
range of cognitive functions, including orientation, working memory, retrograde
amnesia for temporally graded stimuli, and anterograde amnesia. Using a
within-subject, sham-controlled design, the amnestic effects of electroconvulsive
shock (ECS) were evaluated in 2 monkeys. Significant effects of the interventions
(sham and ECS) were seen on all tasks. The degree of impairment varied across
tasks and as a function of task difficulty. ECS did not impair accuracy on the
less difficult tasks (memory for an overlearned item and acquisition of a new
item) but did increase the amount of time required to complete the tasks,
consistent with a period of disorientation acutely after the intervention. This
effect was progressive across the treatments. ECS impaired the acquisition and
memory of new lists compatible with an anterograde memory deficit, whereas recall
for old lists was relatively spared. This study developed and validated a
cognitive battery to assess amnesia in nonhuman primates, providing new
experimental paradigms for evaluating the cognitive effects of convulsive
PMID: 15087994 [PubMed – indexed for MEDLINE] 90. J ECT. 2004 Mar;20(1):3-9.

Propofol reduces cognitive impairment after electroconvulsive therapy.

Butterfield NN, Graf P, Macleod BA, Ries CR, Zis AP.

Department of Pharmacology & Therapeutics, Centre for Anesthesia and Analgesia,
The University of British Columbia, Vancouver, Canada.

Comment in:
J ECT. 2004 Dec;20(4):275.

BACKGROUND: Cognitive impairments are the main complication after
electroconvulsive therapy (ECT). Modification of treatment parameters has been
shown to affect the magnitude of these impairments, but the role of anesthetic
type remains unclear. This study tested whether there is a difference in
cognitive impairments immediately after ECT with propofol compared to thiopental
anesthesia. METHODS: This randomized, double-blind, crossover study included 15
patients receiving right unilateral ECT for depression. Patients received
propofol or thiopental on alternating ECTs up to 6 treatments. Immediate and
delayed verbal memory, motor speed, reaction speed, visuospatial, and executive
functions were assessed 45 minutes after each ECT. Differences were assessed with
repeated measures analysis of variance. RESULTS: Cognitive impairments were
reduced after ECT with propofol compared to thiopental. Time to emergence was
quicker and EEG seizure duration was shorter after propofol treatments. There was
no significant correlation between seizure duration and neuropsychological test
performance. CONCLUSIONS: Our results indicate that cognitive impairments in the
early recovery period after ECT are reduced with propofol compared to thiopental
anesthesia. We suggest that, in addition to ECT parameters, the type of
anesthetic agent should be considered to reduce cognitive impairments after ECT.
PMID: 15087989 [PubMed – indexed for MEDLINE] 91. Epilepsy Behav. 2004 Feb;5(1):3-12.

Focal network involvement in generalized seizures: new insights from
electroconvulsive therapy.

McNally KA, Blumenfeld H.

Department of Neurology and Department of Neurobiology, Yale University School of
Medicine, 333 Cedar Street, New Haven, CT 06520, USA.

Generalized seizures are commonly thought to involve the entire brain
homogeneously. However, recent evidence suggests that selective
cortical-subcortical networks may be crucial for the initiation, propagation, and
behavioral manifestations of generalized seizures, while other brain regions are
relatively spared. Here we review previous studies, and describe a new human
model system for the investigation of generalized seizures: single-photon
emission computed tomography, ictal-interictal difference imaging of generalized
tonic-clonic seizures induced by electroconvulsive therapy (ECT). Bitemporal ECT
activates focal bilateral frontotemporal and parietal association cortex, sparing
other regions; bifrontal ECT activates mainly prefrontal cortex; while in right
unilateral ECT the left frontotemporal region is relatively spared. Associated
midline subcortical networks are also involved. Focal verbal memory deficits
parallel the focal regions involved in these neuroimaging studies. Further
studies of this kind may elucidate specific networks in generalized tonic-clonic
seizures, providing targets for new therapeutic interventions in epilepsy.
PMID: 14751200 [PubMed – indexed for MEDLINE] 92. Bull Acad Natl Med. 2004;188(6):999-1007; discussion 1007-10.

[Depression and aging] [Article in French]

Lôo H, Gallarda T, Fabre I, Olié JP.

Service Hospitalo-Universitaire de Santé Mentale et de Thérapeutique, CH
Sainte-Anne, 1 rue Cabanis, 75674 Paris 14.

Depression is one of the most common health disorders in elderly people. It is
still often considered as a natural consequence of aging, arising in reaction to
a medical disease, cognitive or functional decline, or a loss of social fabric.
Many studies have highlighted the low rates of diagnosis and treatment of
depression, especially in the primary care setting. Major depression in old age
is characterized by the same core symptoms as in other periods of life. However,
aging may accentuate some symptoms and alleviate others. Somatic concern, marked
anxiety, poor subjective memory, psychotic ideation, and recurrent thoughts of
death can mask sadness and anhedonia. Organic factors and adverse life events are
often intricately linked with the pathogenesis of depressive states in the
elderly. The role of cerebrovascular lesions has also been established,
particularly in late-onset depressive disorders. The management of depressive
disorders in older people, as in younger adults, involves pharmacological and
psychological treatments. Electroconvulsive therapy can be beneficial in some
cases. Transcranial magnetic stimulation is being evaluated in this setting.
PMID: 15651428 [PubMed – indexed for MEDLINE] 93. Schizophr Bull. 2004;30(1):185-9.

Absence of additional cognitive impairment in schizophrenia patients during
maintenance electroconvulsive therapy.

Rami L, Bernardo M, Valdes M, Boget T, Portella MJ, Ferrer J, Salamero M.

Clinic Institute of Psychiatry and Psychology, Clinic Hospital of Barcelona, and
Department of Psychiatry and Clinical Psychobiology, University of Barcelona,

This study examines the cognitive impairment profile of schizophrenia patients
during maintenance electroconvulsive therapy (M-ECT). Ten schizophrenia patients
treated with M-ECT and ten control patients matched for diagnosis, sex, and age
who had never been treated with ECT were assessed with a comprehensive
neuropsychological battery. M-ECT patients did not show a higher level of memory,
attention, or frontal function impairment than the control group. The absence of
additional memory dysfunction may favor the functional adaptation of these
patients during M-ECT.
PMID: 15176772 [PubMed – indexed for MEDLINE] 94. J ECT. 2003 Dec;19(4):217-20.

Electroconvulsive therapy clinics in the United Kingdom should routinely monitor
electroencephalographic seizures.

Benbow SM, Benbow J, Tomenson B.

Wolverhapmton City Primary Care Trust and Wolverhampton University, Manchester,

Information recorded during electroconvulsive therapy for all patients treated in
Central Manchester was analyzed to examine the range of seizure thresholds, the
frequency of prolonged seizures, and the difference between the length of motor
and electroencephalographic seizure activity. Prolonged seizures occurred in 19%
of courses studied. EEG seizure length was significantly longer than observed
motor seizure length. EEG monitoring will detect prolonged seizures and should be
performed routinely in ECT clinics in the United Kingdom.
PMID: 14657774 [PubMed – indexed for MEDLINE] 95. Neuropsychol Rev. 2003 Dec;13(4):199-219.

The electroconvulsive therapy controversy: evidence and ethics.

Reisner AD.

Appalachian Behavioral Healthcare, Cambridge Psychiatric Hospital, Cambridge,
Ohio 43725, USA.

The author reviews literature pertaining to the efficacy and safety of
electroconvulsive therapy (ECT), with emphasis on the controversy concerning
whether ECT causes brain damage. ECT does appear to be effective in the treatment
of severe depression and possibly mania. The types of memory problems caused by
ECT are discussed, and evidence suggests that most of these deficits are
transitory. Although most evidence points toward modern ECT not causing brain
damage, there are still some findings that raise questions about safety. Ethical
issues involving this treatment’s use, its availability to the public, and
informed consent procedures are discussed.
PMID: 15000226 [PubMed – indexed for MEDLINE] 96. J ECT. 2003 Sep;19(3):158-63.

Right unilateral ECT at 6x seizure threshold: is it effective in the psychoses?

Little JD, Munday J, Atkins M.

Grampians Psychiatric Services, Ballarat, Victoria, Australia.

OBJECTIVE: To date, right unilateral electroconvulsive therapy administered at 6x
seizure threshold (6x RUL-ECT) has been described in relation to unipolar
depression alone. For clinicians who have developed an experience and confidence
in bilateral ECT, the effectiveness of 6x RUL-ECT in other psychiatric disorders,
particularly those who are severely ill, has remained untested and therefore
unknown. This article describes the results of 6x RUL-ECT in a select series of
patients with a nondepressive psychotic illness. METHOD: Six patients with
psychotic disorders of nondepressive origin were selected from a recent 2-year
retrospective review of 6x RUL-ECT practice. The clinical presentation, ECT
parameters, and responses were recorded. RESULTS: Four patients with severe
psychotic disorders, two of whom met broad criteria for catatonia, responded to
an index course of 6x RUL-ECT. One psychogeriatric patient who had protracted
inpatient mania continues to benefit from outpatient maintenance 6x RUL-ECT over
18 months. Two elderly males, in whom seizures were difficult to elicit and
maintain, responded poorly. CONCLUSION: 6x RUL-ECT was effective in 4 patients
with nondepressive, psychotic disorders. While clinically viable and although
memory was not assessed, it is uncertain what advantage 6x RUL-ECT confers over a
bilateral electrode placement. The real focus should remain on clinical
PMID: 12972986 [PubMed – indexed for MEDLINE] 97. J ECT. 2003 Sep;19(3):148-50.

The relationship between changes in learning and memory after right unilateral
electroconvulsive therapy.

Frasca TA, Iodice A, McCall WV.

Department of Psychiatry and Behavioral Medicine, Wake Forest University School
of Medicine, Winston-Salem, North Carolina 27157, USA.

OBJECTIVE: We investigated whether the ability to learn new information, as
opposed to recall information, would change significantly in depressed
individuals treated by low- or high-dose right unilateral electroconvulsive
therapy and tested whether change in learning explained changes in recall.
METHOD: Fifty-four depressed patients randomized to receive right unilateral
electroconvulsive therapy (ECT) at approximately 2.25 times their seizure
threshold (ST) or at doses greater than 2.25 times ST were evaluated for verbal
and figural memory as well as verbal and figural learning both pre- and post-ECT.
A subset of scores from the Rey Auditory Visual Learning Test and the Rey Figure
Test were analyzed using analysis of variance and linear regression techniques.
RESULTS: Scores reflecting verbal learning decreased by a mean of approximately
50% immediately after a completed course of ECT as compared with pre-ECT verbal
learning scores. Stratification of effect by dose of electrical charge revealed
trends that did not achieve statistical significance. Approximately 8% of the
change in delayed verbal recall was predicted by changes in verbal learning.
Figural learning was not significantly changed in the aggregate (pre-versus
post-treatment) or when the effect was stratified by electrical charge.
CONCLUSIONS: Verbal learning scores declined immediately after ECT, but the
change in learning scores explained only a minor part of the observed changes in
verbal recall. These findings support the notion that the deficits in delayed
recall after ECT represent a relatively specific cognitive effect that is not
completely explained by changes in other aspects of cognition such as learning.
PMID: 12972984 [PubMed – indexed for MEDLINE] 98. Neuroimage. 2003 Aug;19(4):1556-66.

Selective frontal, parietal, and temporal networks in generalized seizures.

Blumenfeld H, Westerveld M, Ostroff RB, Vanderhill SD, Freeman J, Necochea A,
Uranga P, Tanhehco T, Smith A, Seibyl JP, Stokking R, Studholme C, Spencer SS,
Zubal IG.

Department of Neurology, Yale University School of Medicine, 333 Cedar Street,
New Haven, CT 06520, USA.

Are “generalized” seizures truly generalized? Generalized tonic-clonic seizures
are classified as either secondarily generalized with local onset or primarily
generalized, without known focal onset. In both types of generalized seizures
widespread regions of the nervous system engage in abnormally synchronous and
high-frequency neuronal firing. However, emerging evidence suggests that all
neurons are not homogeneously involved; specific nodes within the network may be
crucial for the propagation and behavioral manifestations of generalized
tonic-clonic seizures. Study of human tonic-clonic seizures has been limited by
problems with patient movement and variable seizure types. To circumvent these
problems, we imaged generalized tonic-clonic seizures during electroconvulsive
therapy, in which seizure type and timing are well controlled.
(99m)Tc-hexamethylpropylene amine oxime injections during seizures provide a
“snapshot” of cerebral blood flow that can be imaged by single photon emission
computed tomography (SPECT) after seizure termination. Here we show that focal
regions of frontal and parietal association cortex show the greatest relative
signal increases. Involvement of the higher-order association cortex may explain
the profound impairment of consciousness seen in generalized seizures. In
addition, focal involvement of the dominant temporal lobe was associated with
impaired retrograde verbal memory. Similar focal increases were also seen in
imaging of spontaneous secondarily generalized tonic-clonic seizures. Relative
sparing of many brain regions during both spontaneous and induced seizures
suggests that specific networks may be more important than others in so-called
generalized seizures.
PMID: 12948711 [PubMed – indexed for MEDLINE] 99. Psychiatry Res. 2003 Jul 30;123(3):165-70.

Targeted prefrontal cortical activation with bifrontal ECT.

Blumenfeld H, McNally KA, Ostroff RB, Zubal IG.

Department of Neurology, Yale University School of Medicine, 333 Cedar Street,
New Haven, CT 06520, USA.

The anatomical brain regions involved in the therapeutic and adverse actions of
electroconvulsive therapy (ECT) are unknown. Previous studies suggest that
bifrontal vs. bitemporal ECT differ in therapeutic efficacy and cognitive side
effects. We therefore performed cerebral blood flow (CBF) imaging during
bitemporal vs. bifrontal ECT-induced seizures to identify regions crucial for the
differences between these treatments. Patients with major depression, undergoing
bitemporal or bifrontal ECT, were studied. Ictal-interictal SPECT images were
analyzed with statistical parametric mapping for bitemporal (n=11 image pairs in
8 patients) and bifrontal (n=4 image pairs in 2 patients) ECT-induced seizures to
identify regions of ictal CBF changes. Bifrontal ECT was found to cause increases
in CBF in prefrontal and anterior cingulate regions. Bitemporal ECT, however,
caused CBF increases in the lateral frontal cortex and in the anterior temporal
lobes. In bifrontal ECT, a greater increase in prefrontal activation, while
sparing the temporal lobes, may result in a better therapeutic response and fewer
adverse effects on memory than bitemporal ECT.
PMID: 12928104 [PubMed – indexed for MEDLINE] 100. J Neuropsychiatry Clin Neurosci. 2003 Summer;15(3):333-9.

The influence of cognitive reserve on memory following electroconvulsive therapy.

Legendre SA, Stern RA, Solomon DA, Furman MJ, Smith KE.

University of Rhode Island, Kingston, Rhode Island, USA.

Cognitive reserve (CR) theory proposes that certain genetic and nonacquired
variables, such as larger head size and greater neuronal density, and some life
experiences, such as higher educational and occupational attainment, provide a
buffer against brain dysfunction in the face of acquired central nervous system
(CNS) dysfunction. This study examined CR in the pseudoexperimental paradigm of
electroconvulsive therapy (ECT). Subjects included fifty (N = 50) depressed
patients treated with bilateral ECT. Subjects were placed in high (n = 27) or low
(n = 23) CR groups based on years of education and occupational attainment. At
baseline, no significant differences were observed between the groups in the
amount of information forgotten on a verbal memory measure (Randt stories) after
a 30-minute delay. Following three ECT treatments, however, the high CR group
forgot significantly less information after a 30-minute delay, as compared to the
low CR group (p < 0.01). These data provide further support for CR theory and
suggest that CR may be an underlying factor in differential memory loss in ECT.
PMID: 12928509 [PubMed – indexed for MEDLINE] 101. BMJ. 2003 Jun 21;326(7403):1363.

Patients’ perspectives on electroconvulsive therapy: systematic review.

Rose D, Fleischmann P, Wykes T, Leese M, Bindman J.

Service User Research Enterprise, PO34, Institute of Psychiatry, De Crespigny
Park, London SE5 8AF.

Comment in:
Evid Based Ment Health. 2004 Feb;7(1):27.

OBJECTIVE: To ascertain patients’ views on the benefits of and possible memory
loss from electroconvulsive therapy. DESIGN: Descriptive systematic review. DATA
SOURCES: Psychinfo, Medline, Web of Science, and Social Science Citation Index
databases, and bibliographies. STUDY SELECTION: Articles with patients’ views
after treatment with electroconvulsive therapy. DATA EXTRACTION: 26 studies
carried out by clinicians and nine reports of work undertaken by patients or with
the collaboration of patients were identified; 16 studies investigated the
perceived benefit of electroconvulsive therapy and seven met criteria for
investigating memory loss. DATA SYNTHESIS: The studies showed heterogeneity. The
methods used were associated with levels of perceived benefit. At least one third
of patients reported persistent memory loss. CONCLUSIONS: The current statement
for patients from the Royal College of Psychiatrists that over 80% of patients
are satisfied with electroconvulsive therapy and that memory loss is not
clinically important is unfounded.
PMCID: PMC162130
PMID: 12816822 [PubMed – indexed for MEDLINE] 102. Clin Neurophysiol. 2003 Jun;114(6):1125-32.

Neurocognitive effects of repetitive transcranial magnetic stimulation in severe
major depression.

Martis B, Alam D, Dowd SM, Hill SK, Sharma RP, Rosen C, Pliskin N, Martin E,
Carson V, Janicak PG.

Department of Psychiatry, Psychiatric Clinical Research Center and Center for
Cognitive Medicine, University of Illinois at Chicago, 912 South Wood Street
Suite 137 MC 913, Chicago, IL 60612, USA.

OBJECTIVE: Repetitive transcranial magnetic stimulation (rTMS) is being
investigated as a potential treatment for depression. Few studies have addressed
the neurocognitive effects of a course of rTMS in severely depressed patients. We
evaluated neurocognitive effects of a 1-4 week course (mean 3 weeks) of rTMS
using an aggressive set of parameters, in 15 severely depressed subjects.
METHODS: A battery of neurocognitive tests relevant to attention, working
memory-executive function, objective memory and motor speed were administered to
15 subjects with treatment-resistant major depression (unipolar and bipolar),
before and after a course of rTMS. Mean z scores were computed for each of 4
cognitive domains and analyzed using repeated measures multivariate analysis of
covariance. Significant interactions were further clarified using univariate
analysis of variance. RESULTS: There was no worsening of performance on any of
the cognitive domains over the baseline-post rTMS period. On the contrary,
evidence of modest but statistically significant improvement in performance was
noted in working memory-executive function, objective memory and fine motor speed
domains over the rTMS treatment period. CONCLUSIONS: There was no evidence of
adverse neurocognitive changes over the baseline-post rTMS period in 15
treatment-resistant depressed subjects undergoing a 3 week (mean) trial of rTMS.
Significant improvements in several domains observed over the rTMS treatment
period could not be explained by improved mood. Practice effects as well as other
factors potentially contributing to these findings are discussed. SIGNIFICANCE:
rTMS is being increasingly studied as a neurophysiological probe as well as for
its potential antidepressive effects. The effects on neuronal function raise
appropriate questions of safety of its use at varying stimulus parameters and
durations. This study contributes to the small body of evidence of the cognitive
effects of rTMS in severely depressed patients.
PMID: 12804681 [PubMed – indexed for MEDLINE] 103. Cogn Behav Neurol. 2003 Jun;16(2):118-27.

Relative effects of repetitive transcranial magnetic stimulation and
electroconvulsive therapy on mood and memory: a neurocognitive risk-benefit

O’Connor M, Brenninkmeyer C, Morgan A, Bloomingdale K, Thall M, Vasile R, Leone

Harvard Medical School, Boston, Massachusetts, USA.

OBJECTIVE: Two procedures for treating major depressive disorder were compared
with regard to their respective effects on mood and cognition. BACKGROUND:
Fourteen patients underwent treatment with electroconvulsive therapy and 14
underwent treatment with repetitive transcranial magnetic stimulation. Patients
were tested on three occasions: before initiation of treatment, at the end of
treatment, and 2 weeks after the end of treatment. METHODS: Electroconvulsive
therapy was applied unilaterally approximately three times per week for 2 to 4
weeks. Repetitive transcranial magnetic stimulation was applied in sessions of
1600 stimuli at 10 Hertz and 90% of motor threshold intensity to the left
dorsolateral prefrontal cortex daily (Monday through Friday) for 2 consecutive
weeks. RESULTS: Results indicate that electroconvulsive therapy had a more
positive effect on mood than did a 2-week trial of repetitive transcranial
magnetic stimulation. With regard to cognitive outcome measures,
electroconvulsive therapy exerted a deleterious but transient effect on various
components of memory that were no longer detected 2 weeks after the end of
treatment; however, there was evidence of persistent retrograde amnesia after
treatment with electroconvulsive therapy. As a group, repetitive transcranial
magnetic stimulation patients experienced only a modest reduction in depression
severity but there was no evidence of anterograde or retrograde memory deficits
in the aftermath of treatment with repetitive transcranial magnetic stimulation.
CONCLUSIONS: Findings suggest that electroconvulsive therapy is associated with
transient negative cognitive side effects, most of which dissipate in the days
after treatment. Deficits of this sort are not apparent after treatment with a
2-week course of repetitive transcranial magnetic stimulation.
PMID: 12799598 [PubMed – indexed for MEDLINE] 104. J ECT. 2003 Jun;19(2):93-7.

ECT in the Asia Pacific region: what do we know?

Little JD.

Grampians Psychiatric Services, Victoria, Australia.

OBJECTIVE: To review and describe the practice of ECT in the Asia Pacific region
in the year 2000. METHOD: A survey of 34 defined countries within the Asia
Pacific region was made prior to the 1st Asia Pacific ECT Conference held in
Melbourne, Australia, 2001. RESULTS: Contact addresses for 23 of 34 countries
(70%) were found with responses from 12 different countries (35%). Individual
responses were received from less than 1% of the total mail out for the
conference. The percentage of inpatients who received ECT was consistently less
than or equal to 9%, except for Nepal where it was 25.6%. Except for Kiribati and
the Solomon Islands, all devices delivered brief pulse, square wave currents. All
of the 12 countries surveyed used anesthesia, preferred bilateral electrode
placement and reported a response rate of at least 86%. Adverse events were
uncommon, memory being the most commonly reported side effect. Community
attitudes were generally negative. CONCLUSION: Despite the difficulties in
attempting to generalize about this huge and diverse region, a number of
seemingly universal findings appeared in accord with the world literature. These
included the widespread use of ECT, its effectiveness and its relative safety
despite equally widespread community reluctance.
PMID: 12792458 [PubMed – indexed for MEDLINE] 105. Psychiatr Pol. 2003 May-Jun;37(3):445-55.

[Electroconvulsive therapy in the treatment of depression in elderly] [Article in Polish]

Hordy?ska E, Pali?ska D, Sobów T.

I Kliniki Psychiatrycznej Akademii Medycznej w ?odzi.

INTRODUCTION: The use of a electroconvulsive therapy (ECT) in the elderly
suffering from depression is still controversial in Poland. Not only
psychiatrists but also specialists who qualify the patients for ECT–internal
medicine specialists, neurologists and anaesthesiologists–treat the advanced age
of a patient as a contraindication to ECT. It is also believed that ECT has
adverse influence on the mental state of patients with the so-called
psychoorganic syndrome. In most centres in Poland ECT is reserved for patients
with drug-resistant depression and those in whom pharmacotherapy is
contraindicated for any reason, such as pregnancy. Nevertheless the patients are
carefully selected with respect to their physical condition. In many countries
however the older the patient, the more likely he/she is to receive ECT as a
method of choice. The effectiveness of this method in elderly patients is
considered to be higher than in younger groups. ECT seems to be particularly
effective in depression with psychotic symptoms and psychomotor retardation. The
adverse effect of ECT on cognitive functions (learning and memory) which is a
great concern of both doctors and patients, is actually noted in a small group of
patients and usually transient. Moreover, the frequency of occurrence of this
effect in elderly is not greater than in younger patients. AIM: We have been
encouraged to write this paper by very promising results achieved in patients
treated with ECT in the Psychogeriatric Ward of the Ist Department of Psychiatry,
Medical University of ?ód?. METHOD: All 7 patients were diagnosed with severe
depressive episode (in 4 cases with psychotic symptoms) in the course of either
recurrent depression (6 cases) or bipolar disorder (1 case). RESULTS: In all
patients at least partial improvement was noted. It seems that ECT, assuming
careful patient qualification, is an effective and safe method of therapy in
elderly patients.
PMID: 13677974 [PubMed – indexed for MEDLINE] 106. Actas Esp Psiquiatr. 2003 Mar-Apr;31(2):69-72.

[Assessment of frontal functions in psychiatric patients during maintenance
electroconvulsive therapy] [Article in Spanish]

Rami-González L, Bernardo M, Portella MJ, Goti J, Gil-Verona JA, Salamero M.

Instituto Clínico de Psiquiatría y Psicología, Hospital Clínico y Provincial de
Barcelona, Barcelona, Spain.

INTRODUCTION: Previous studies on adverse cognitive effects of electroconvulsive
therapy (ECT) have not found any significant alteration of the frontal functions
after an acute treatment course. This study aims to assess frontal executive
functions in psychiatric patients during maintenance electroconvulsive therapy
(M-ECT). SUBJECTS AND METHODS: Thirty two patients treated with M-ECT and 29
psychiatric patients never treated with ECT were evaluated with
neuropsychological tests that assessed the following frontal functions: work
memory, planning, cognitive flexibility, attention, visuomotor velocity, verbal
abstract reasoning and phonetic verbal fluency. RESULTS: Multivariate global
analysis did not detect significant frontal function tests differences between
both groups. The M-ECT group only scored significantly lower on the FAS test, a
test that measures phonetic verbal fluency. A significant correlation between
number of previous ECT sessions and performance in the FAS was found.
CONCLUSIONS: The M-ECT patient group presented a phonetic verbal fluency
alteration that may also be associated to the previous number of ECT sessions. No
significant differences in the other frontal functions were detected.
PMID: 12677470 [PubMed – indexed for MEDLINE] 107. Aust N Z J Psychiatry. 2003 Feb;37(1):49-54.

The subjective experience of patients who received electroconvulsive therapy.

Koopowitz LF, Chur-Hansen A, Reid S, Blashki M.

Department of Psychiatry, University of Adelaide, South Australia, Australia.

OBJECTIVE: Despite the vast amount of scientific literature available on
electroconvulsive therapy (ECT), there is little qualitative focus upon the
patients’ subjective experience of this procedure. Using an exploratory
descriptive methodology, this study aims to provide a more unique insight into
what certain patients actually think of ECT. METHOD: Semistructured interviews
were conducted to explore eight patients’ opinions and experiences of ECT.
Interviews were subjected to analysis by a five-step framework approach that
identified prominent themes in relation to five broad questions and in
conjunction with issues raised by the subjects themselves. RESULTS: Eleven major
themes were identified. Four of these were chosen for discussion, not only as the
most prevalent themes (in terms of how frequently they were mentioned by the
subjects), but also as the most striking (in regards to the intensity of emotions
evoked, or their influence on their perception of ECT as a future treatment
option). The four themes are fear of ECT, attribution of cognitive decline and
memory loss to ECT, positive ECT experiences, and patients’ suggestions.
CONCLUSIONS: Using such a qualitative approach, the depth of the information
obtained has revealed new perspectives on how patients perceive the experience of
ECT. Fears reported by patients present an opportunity to address specific areas
of the procedure that generate the most angst. These were closely associated with
recommendations that many patients proposed throughout the interviews. Patients’
perceptions of the cognitive effects of ECT do not necessarily correspond with
those commonly reported in the literature on ECT. Positive experiences with ECT
were more complex than simply its efficacy. There is a need for future research
in order to explore and address patients’ experiences of ECT.
PMID: 12534656 [PubMed – indexed for MEDLINE] 108. Psychol Med. 2003 Feb;33(2):345-50.

Pattern of cognitive dysfunction in depressive patients during maintenance
electroconvulsive therapy.

Rami-González L, Salamero M, Boget T, Catalan R, Ferrer J, Bernardo M.

Institute of Psychiatry and Psychology, Hospital Clinic, Barcelona, Spain.

BACKGROUND: Objective data regarding adverse cognitive deficits associated with
maintenance electroconvulsive therapy (M-ECT) are lacking. This study examined
the cognitive state of depressive patients during M-ECT. METHOD: A
cross-sectional study was carried out in 11 depressive patients in remission, all
with a DSM-IV diagnosis of major depressive disorder. The mean number of previous
ECT sessions was 36.1, and the mean intersession interval was 52.7 days. A group
of 11 patients who had not received ECT was selected for comparison and matched
for diagnosis, sex, age and years of schooling. All subjects were assessed using
a complete neuropsychological battery including memory, attention and frontal
function tests. RESULTS: Groups did not present differences in long delay verbal
recall. Encoding of new information and results on the frontal function tests
were significantly lower in the M-ECT patients. CONCLUSION: Depressed patients
preserve long-term memory, but suffer short-term memory impairment and frontal
function alteration during M-ECT. Further longitudinal studies are necessary to
determine the influence of M-ECT on non-memory functions and different memory
PMID: 12622313 [PubMed – indexed for MEDLINE] 109. Bull Menninger Clin. 2003 Winter;67(1):18-31.

Clinical applications of recent research on electroconvulsive therapy.

Rasmussen KG.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota 55905,

Electroconvulsive therapy (ECT) has been in use since the late 1930s to treat a
variety of severe mental illnesses, most notably major depression. Current
research efforts focus on patient selection, memory impairment, and high
posttreatment relapse rates. Psychopathological factors such as psychosis and
severe psychomotor retardation predict favorable response to ECT in depression.
Technical variables that affect memory include electrode placement, stimulus
intensity, and treatment frequency. Strategies to reduce posttreatment relapse
rates include maintenance ECT and aggressive medication combinations. In this
article, I review recent research that bears on these aspects of ECT practice.
Additionally, I review some findings on the neurobiological effects of ECT.
PMID: 12809371 [PubMed – indexed for MEDLINE] 110. J ECT. 2002 Dec;18(4):207-12.

Patients’ and their relatives’ knowledge of, experience with, attitude toward,
and satisfaction with electroconvulsive therapy in Hong Kong, China.

Tang WK, Ungvari GS, Chan GW.

Department of Psychiatry, Chinese University of Hong Kong, China.

Although electroconvulsive therapy (ECT) is a safe and efficacious treatment,
there is a widespread negative view of ECT in public and professional circles.
There are no data on Chinese patients’ knowledge of, experience with, attitude
toward, and level of satisfaction with ECT in Hong Kong. The aims of this study
were to examine patients’ experience of ECT, and patients’ and their relatives’
knowledge of, attitude toward, and level of satisfaction with ECT. To this
effect, a prospective cross-sectional survey was conducted, involving 96 patients
and their 87 relatives. The study showed that the majority of patients believed
they had not received adequate information about ECT. The most commonly reported
side effect was memory impairment. Patients and relatives had only limited
knowledge of ECT, yet the majority of them were satisfied with the treatment and,
having found it beneficial, maintained a positive attitude toward its use. The
researchers concluded that Hong Kong Chinese patients and their relatives
accepted ECT as a treatment. The way information is provided to patients and
relatives when obtaining consent for ECT needs improvement.
PMID: 12468997 [PubMed – indexed for MEDLINE] 111. J ECT. 2002 Dec;18(4):197-202.

Effect of stimulus intensity and number of treatments on ECS-related seizure
duration and retrograde amnesia in rats.

Andrade C, Thyagarajan S, Vinod PS, Srikanth SN, Rao NS, Chandra JS.

Department of Psychopharmacology, National Institute of Mental Health and
Neurosciences, Bangalore, India. andrade@nimhans.kar

BACKGROUND: Animal models are frequently used to generate and test hypotheses
about amnesia resulting from electroconvulsive therapy (ECT). Although many
predictors of ECT-induced amnesia are known, their relative effects have been
inadequately researched in the context of the animal models. OBJECTIVE: We sought
to determine the relative retrograde amnestic effects of electroconvulsive shock
(ECS) stimulus intensity (dose) and number on strong memories in rats. We also
sought to identify dose-dependent ceiling amnestic effects, if any. METHODS:
Adult rats (n = 144) were overtrained in a passive avoidance task using a step
down apparatus. The rats were then randomized in a factorial design to receive
one, two, or three once-daily bilateral ECS at 0-mC (sham ECS), 30-mC, 60-mC,
120-mC, or 180-mC doses. Recall of the pre-ECS training was assessed 1 day after
the last ECS. RESULTS: Retrograde amnesia was observed only in rats that received
3 ECS; dose-dependent amnestic effects did not emerge. Higher stimulus intensity
was associated with a small (13%) but significant increase in motor seizure
duration, but only at the first ECS; stimulus intensity did not influence the
attenuation of seizure duration across repeated occasions of ECS. CONCLUSION:
With bilateral ECS, the number of ECSs administered is a more important variable
than the ECS dose in weakening a strong, recently acquired, noxious memory; this
finding may have important clinical implications. Higher stimulus intensity
marginally increases motor seizure duration at the first ECS but does not
influence the decrease in seizure duration across repeated ECSs.
PMID: 12468995 [PubMed – indexed for MEDLINE] 112. Psychiatr Pol. 2002 Nov-Dec;36(6 Suppl):157-66.

[Electroconvulsive therapy in the treatment of depression in the elderly] [Article in Polish]

Hordy?ska E, Pali?ska D, Sobów T.

I Klinika Psychiatryczna AM w ?odzi.

In this paper we discuss seven cases of major depression in elderly (age > 60)
treated with ECT. Six suffered from unipolar disorder and one from bipolar; four
of them had psychotic features. In all patients at least some improvement was
gained. Memory impairment appeared in two patients, however in one case no
abnormalities in neuropsychological tests were found; in the second patient
memory impairment, which could have been seen before treatment, became slightly
more pronounced. In one patient after injection used for anaesthesia convulsion
(type grand mal) occurred, but when the medicine was changed all ECT sessions
were successful without any side effects. In three patients ECT had been
successfully used before and was still efficient during our study. In other three
patients ECT as prevention is still being used. Our first experience with ECT in
elderly patients is highly encouraging, especially after careful selection of
PMID: 12647435 [PubMed – indexed for MEDLINE] 113. Rev Neurol. 2002 Nov 1-15;35(9):805-8.

[Selective alteration of the declarative memory systems in patients treated with
a high number of electroconvulsive therapy sessions] [Article in Spanish]

Rami-González L, Boget-Llucià T, Bernardo M, Marcos T, Cañizares-Alejos S,
Penadés R, Portella MJ, Castelví M, Raspall T, Salamero M.

Servicio de Psicología. Hospital Clínic i Provincial de Barcelona, Barcelona,

INTRODUCTION: The reversible electrochemical effects of electroconvulsive therapy
(ECT) on specific areas of the brain enable the neuroanatomical bases of some
cognitive functions to be studied. In research carried out on memory systems, a
selective alteration of the declarative ones has been observed after treatment
with ECT. Little work has been done to explore the differential alteration of the
memory subsystems in patients with a high number of ECT sessions. AIM. To study
the declarative and non declarative memory system in psychiatric patients
submitted to maintenance ECT treatment, with a high number of previous ECT
sessions. PATIENTS AND METHODS: 20 patients submitted to treatment with ECT (10
diagnosed as having depression and 10 with schizophrenia) and 20 controls, who
were paired by age, sex and psychopathological diagnosis. For the evaluation of
the declarative memory system, the Wechsler Memory Scale (WMS) logical memory
test was used. The Hanoi Tower procedural test was employed to evaluate the non
declarative system. RESULTS: Patients treated with ECT performed worse in the WMS
logical memory test, but this was only significant in patients diagnosed as
suffering from depression. No significant differences were observed in the Hanoi
Tower test. CONCLUSIONS: A selective alteration of the declarative systems was
observed in patients who had been treated with a high number of ECT sessions,
while the non declarative memory systems remain unaffected.
PMID: 12436375 [PubMed – indexed for MEDLINE] 114. Epilepsia. 2002 Sep;43(9):956-63.

Effect of gabapentin on the anticonvulsant activity of antiepileptic drugs
against electroconvulsions in mice: an isobolographic analysis.

Borowicz KK, Swiader M, Luszczki J, Czuczwar SJ.

Department of Pathophysiology and Department of Pharmacology and Toxicology,
Medical University, and Isotope Laboratory, Institute of Agricultural Medicine,
Lublin, Jaczewskiego, Poland.

PURPOSE: The objective of this study was the isobolographic evaluation of the
interactions between the novel antiepileptic drug (AED) gabapentin (GBP) and a
number of other AEDs against electroconvulsion-induced convulsions in mice.
METHODS: Electroconvulsions were produced by means of an alternating current
(ear-clip electrodes, 0.2-s stimulus duration, tonic hindlimb extension taken as
the end point). Adverse effects were evaluated with the chimney test (motor
performance) and passive-avoidance task (long-term memory). Plasma levels of AEDs
were measured by immunofluorescence or high-pressure liquid chromatography.
RESULTS: GBP (< or =50 mg/kg) remained ineffective on the electroconvulsive
threshold. According to the isobolographic analysis, GBP appears to act
synergistically with carbamazepine, valproate, phenytoin, phenobarbital (PB),
lamotrigine (LTG), and LY 300164. The pharmacokinetic events may be responsible
for the interactions of GBP/PB and GBP/LTG, because only PB and LTG significantly
elevated the plasma concentration of this AED. Conversely, GBP did not affect the
plasma levels of other AEDs used in this study. No adverse effects were induced
by combinations of GBP with these AEDs. CONCLUSIONS: The isobolographic analysis
revealed that combinations of GBP with other AEDs generally results in
synergistic (supraadditive) interactions.
PMID: 12199720 [PubMed – indexed for MEDLINE] 115. J ECT. 2002 Sep;18(3):162-4.

Electroconvulsive therapy in a patient receiving rivastigmine.

Zink M, Sartorius A, Lederbogen F, Henn FA.

Department of Psychiatry, Central Institute of Mental Health, Mannheim, Germany.

We report the case of an 81-year-old woman, suffering from a major depressive
episode and incipient Alzheimer disease, whom we treated with ECT without
interrupting therapy with the acetylcholinesterase inhibitor (ACHE-I)
rivastigmine. After eight right unilateral ECT sessions, the patient remitted
completely without any significant deterioration of memory and cognitive
abilities or cholinergic side effects. This report demonstrates that ECT was
safely used in one elderly and mildly demented person with continuous ACHE-I
therapy. The hypothesis that this drug may indeed protect against unfavorable
side effects of ECT should be further tested in clinical trials.
PMID: 12394536 [PubMed – indexed for MEDLINE] 116. J ECT. 2002 Sep;18(3):130-7.

Effect of piracetam on ECT-induced cognitive disturbances: a randomized,
placebo-controlled, double-blind study.

Tang WK, Ungvari GS, Leung HC.

Department of Psychiatry, Chinese University of Hong Kong, Hong Kong, SAR, China.

Comment in:
J ECT. 2003 Jun;19(2):122.

Electroconvulsive therapy (ECT) is still the fastest, most effective, and
frequently life-saving therapeutic intervention in several forms of depression
and some other psychiatric disorders. Transient memory disturbances are frequent
after ECT. A randomized, double-blind, placebo-controlled study was conducted to
investigate the effects of piracetam on ECT-induced confusion and memory
disturbances. Thirty-eight consecutively admitted patients with depressive
illness or schizophrenia requiring ECT were given either piracetam or an
identical-looking placebo during the period of ECT treatment and for 2 weeks
afterward. Daily dosage of piracetam was 7.2 g, given orally for the first 2
weeks while patients underwent ECT (loading phase), followed by 4.8 g for the
rest of the study period. Participants were evaluated by standardized clinical
rating scales and cognitive psychologic tests 1 to 2 days before ECT, 1 day after
their third and sixth ECT treatments, and 2 weeks after they had completed their
ECT courses. Piracetam had no significant effect in preventing ECT-induced memory
disturbances. All clinical ratings were consistently, albeit not significantly,
better in the piracetam group, suggesting that piracetam may have augmented the
effects of ECT.
PMID: 12394531 [PubMed – indexed for MEDLINE] 117. J ECT. 2002 Sep;18(3):126-9.

Markedly suprathreshold right unilateral ECT versus minimally suprathreshold
bilateral ECT: antidepressant and memory effects.

McCall WV, Dunn A, Rosenquist PB, Hughes D.

Department of Psychiatry and Behavioral Medicine, Wake Forest University School
of Medicine,Winston-Salem, North Carolina27127, USA.

Comment in:
J ECT. 2003 Jun;19(2):121; author reply 121-2.

Right unilateral (RUL) ECT is reported to have fewer memory side effects than
bilateral (BL) ECT. We compared RUL ECT at eight times the seizure threshold (ST)
against BL ECT at 1.5 times the ST. Adults with major depression were randomly
assigned to RUL ECT at eight times ST or BL ECT at 1.5 times the ST. Blinded
ratings of mood and memory were made before ECT, 1 to 3 days after the final ECT,
and at 2 and 4 weeks after ECT. Forty patients received RUL and 37 received BL
ECT. The antidepressant response rate was not significantly different for the RUL
and BL groups (60% vs. 73%). Sustained antidepressant response, accompanied by
recovery from anterograde memory side effects, was seen through the first month
with both treatments. Measures of mood and memory were not significantly
different for the two groups at any time point. The modest sample sizes of this
study do not rule out a type II error in the detection of small but meaningful
differences between assigned treatments. Also, the period of post-ECT observation
consisted of 1 month of naturalistic treatment. Both RUL ECT at eight times the
ST and BL ECT at 1.5 times the ST produce similar mood and memory effects. Both
forms of ECT produced acceptable antidepressant response rates and only transient
anterograde amnesia. No clear advantage emerged for either form of ECT, and both
are justifiable as first-line techniques of ECT.
PMID: 12394530 [PubMed – indexed for MEDLINE] 118. J Geriatr Psychiatry Neurol. 2002 Summer;15(2):73-6.

Clinical outcome and adverse effects of electroconvulsive therapy in elderly
psychiatric patients.

Kujala I, Rosenvinge B, Bekkelund SI.

Department of Psychiatry, University Hospital of Tromsø, Norway.

We evaluated the short-term outcome and side effects of electroconvulsive
treatment (ECT) in a population of elderly psychiatric patients. The material
included patients consecutively hospitalized at a psychogeriatric department
within a period of 5 years. From a total number of 239 patients, we included 52
treated with ECT (22%). Altogether, 41 patients (79%) improved clinically. Of
them, 21 (40%) of the patients went home after the treatment. Twenty patients
(38%) developed adverse reactions from the ECT treatment. Impaired memory (14%),
confusion (6%), and hypertension (6%) represented the most commonly reported
negative reactions secondary to the treatment. The findings from the study
support previous assumptions that ECT is effective in the treatment of serious
psychiatric disorders in elderly patients. Because of the relative high frequency
of side effects, the patients should be selected
PMID: 12083596 [PubMed – indexed for MEDLINE] 119. Mayo Clin Proc. 2002 Jun;77(6):552-6.

Electroconvulsive therapy and newer modalities for the treatment of
medication-refractory mental illness.

Rasmussen KG, Sampson SM, Rummans TA.

Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minn 55905, USA.

Severe mental illnesses often remain chronic and refractory to medication,
leading to substantial morbidity and mortality. For more than 60 years,
electroconvulsive therapy has been the only nonpharmacological psychiatric
procedure available to treat severe or medication-refractory major depressive
disorder and other psychiatric conditions. Memory dysfunction remains the most
serious adverse effect, and current research focuses on attempts to ameliorate
this complication. Transcranial magnetic stimulation and vagus nerve stimulation,
2 new neuropsychiatric technologies, are emerging as possible additions to our
therapeutic armamentarium. Besides providing therapeutic benefits, these 3
methods may help elucidate the pathophysiology of psychiatric illness.
PMID: 12059125 [PubMed – indexed for MEDLINE] 120. Ethical Hum Sci Serv. 2002 Spring;4(1):63-71.

Electroshock: a crime against the spirit.

Frank LR.

2300 Webster Street, #603, San Francisco, CA 94115, USA.

Since its introduction in 1938, electroshock (electroconvulsive treatment, ECT)
has been to its proponents a blessing and to its critics a curse. The author,
himself an insulin coma-electroshock survivor, sides with the critics arguing
that ECT is inherently harmful and dehumanizing. To support his views, he cites
findings and comments from the professional literature in four areas: brain
damage, memory loss, death, and brainwashing. The author also presents seven
reasons for the continuing use of ECT, including profitability, value as a
reinforcer of the biological model of mental illness, the absence of informed
consent, the procedure’s function as a “treatment of next resort,” government and
media support, and the public’s failure to hold psychiatrists accountable for
their conduct. The author concludes the article with his poem “Aftermath.”
PMID: 15278988 [PubMed – indexed for MEDLINE] 121. J ECT. 2002 Mar;18(1):47-53.

ECT in poetry.

Walter G, Fisher K, Harte A.

Department of Psychological Medicine, University of Sydney and Central Sydney
Area Health Service, Sydney, Australia.

Comment in:
J ECT. 2002 Sep;18(3):167.

We sought to identify poems about Electroconvulsive therapy (ECT) and describe
their major themes, with a view to using some of those poems in clinical
situations-for persons receiving ECT and their families-as well as for teaching
purposes. Several poems were identified, eight almost exclusively about ECT and a
number of other works containing references to the treatment. The poets, some of
whom have won distinguished prizes, came from the United States, U.K., Australia,
and Estonia. The poems included very positive accounts of ECT and more
denigrating pieces. Some of the themes covered by the poems were the desperate
plight of persons prior to ECT, the potentially striking beneficial effects of
the treatment, fears about the use of electricity, ECT procedure, and memory
impairment, and the stigma associated with the treatment.
PMID: 11925522 [PubMed – indexed for MEDLINE] 122. Cochrane Database Syst Rev. 2002;(2):CD000076.

Electroconvulsive therapy for schizophrenia.

Tharyan P, Adams CE.

Department of Psychiatry, Christian Medical College, Vellore, Tamil Nadu, India,

Update in:
Cochrane Database Syst Rev. 2005;(2):CD000076.

Update of:
Cochrane Database Syst Rev. 2000;(2):CD000076.

BACKGROUND: Electroconvulsive therapy (ECT) involves the induction of a seizure
(fit) for therapeutic purposes by the administration of a variable frequency
electrical stimulus shock via electrodes applied to the scalp. The effects of its
use in people with schizophrenia are unclear. OBJECTIVES: To determine whether
electroconvulsive therapy (ECT) results in clinically meaningful benefit with
regard to global improvement, hospitalisation, changes in mental state, behaviour
and functioning for people with schizophrenia, and whether variations in the
practical administration of ECT influences outcome. SEARCH STRATEGY: Electronic
searches of Biological Abstracts (1982-1996), EMBASE (1980-1996), MEDLINE
(1966-2001), PsycLIT (1974-1996),SCISEARCH (1996) and the Cochrane Schizophrenia
Group’s Register (July 2001) were undertaken. The references of all identified
studies were also inspected and authors contacted. SELECTION CRITERIA: All
randomised controlled clinical trials that compared ECT with placebo, ‘sham ECT’,
non-pharmacological interventions and antipsychotics, and different schedules and
methods of administration of ECT for people with schizophrenia, schizoaffective
disorder or chronic mental disorder. DATA COLLECTION AND ANALYSIS: Studies were
reliably selected, quality rated and data extracted. For dichotomous data,
relative risks (RR) were estimated, with the 95% confidence intervals (CI). Where
possible, the number needed to treat statistic (NNT) was calculated. Analysis was
by intention-to-treat. Normal continuous data was summated using the weighted
mean difference (WMD). Scale data was presented for only those tools that had
attained pre-specified levels of quality. Tests of heterogeneity and for
publication bias were undertaken. MAIN RESULTS: This review includes 24 trials
with 46 reports. When ECT is compared with placebo or sham ECT, fewer people
remain unimproved in the real ECT group (n=400, RR fixed ‘not globally improved
in the short term’ 0.77 CI 0.6 to 0.9, chi-square 13.46 df=8 p=0.1). Removal of
the one study with clearly heterogeneous results causes a change in the findings
(n=380, 8 RCTs, RR fixed 0.83 CI 0.7 to 1.01), as does removal of a clinically
heterogeneous trial (n=370, 8 RCTs, RR fixed 0.74 CI 0.6 to 0.9, chi-square 10.97
df=7 p=0.14). There was a suggestion that ECT resulted in less relapses than sham
ECT (n=47, 2 RCTs, RR fixed 0.26 CI 0.03 to 2.2), and a greater likelihood of
being discharged from hospital (n=98, 1 RCT, RR fixed 0.59, CI 0.34 to 1.01).
There is no evidence that this early advantage for ECT is maintained over the
medium to long term. People treated with ECT did not drop out of treatment
earlier than those treated with sham ECT (n=495, 14 RCTs, RR fixed 0.71 CI 0.33
to 1.52). Very limited data indicated that visual memory might decline after ECT
compared with sham ECT (n=24, 1 RCT, WMD -14.0 CI -23 to -5); the results of
verbal memory tests were equivocal. When ECT is directly compared with
antipsychotic drug treatment (total n=419, 8 RCTs), results favour the medication
group (n=175, 3 RCTs, RR fixed ‘not improved at the end of ECT course’ 2.18 CI
1.3 to 3.6). One small study suggested more memory impairment after a course of
ECT combined with antipsychotics than with antipsychotics alone (n=20, MD serial
numbers and picture recall -4.90 CI -0. 8 to -9), though this proved transient.
When continuation ECT was added to antipsychotic drugs, the combination was
superior to the use of antipsychotics alone (n=30, WMD Global Assessment of
Functioning 19.1 CI 9.7 to 28.5), or CECT alone (n=30, WMD -20.3 CI -11.5 to
-29.1). Unilateral and bilateral ECT were equally effective in terms of global
improvement (n=78, 2 RCTs, RR fixed ‘not improved at end of course of ECT’ 0.79
CI 0.5 to 1.4). One trial showed a significant advantage for 20 treatments over
12 treatments for numbers globally improved at the end of the ECT course (n=43,
RR fixed 2.53 CI 1.1 to 5.7). REVIEWER’S CONCLUSIONS: There is no evidence to
clearly refute the use of ECT for people with schizophrenia. There is some
limited evidence to support its use, particularly combined with antipsychotic
drugs for those with schizophrenia who show limited response to medication alone.
The research base for the use of ECT in people with schizophrenia is growing but,
even after more than five decades of clinical use, is still inadequate.
PMID: 12076380 [PubMed – indexed for MEDLINE] 123. Med Hypotheses. 2002 Jan;58(1):24-7.

Delirium and psychotic symptoms–an integrative model.

Charlton BG, Kavanau JL.

Department of Psychology, University of Newcastle-upon-Tyne, UK.

Delirium may be a common cause of psychotic symptoms such as hallucinations,
bizarre delusions and thought-disorder, even in conditions such as schizophrenia,
mania and depression, where delirium has traditionally been excluded by
definition. This situation is a consequence of the insensitivity of current
clinical criteria for the diagnosis of delirium, which recognize only the most
severe forms of functional brain impairment (including disorientation and
clouding of consciousness). Serial electroencephalograms (EEGs) are the most
sensitive method for detecting delirium, and until such studies are performed,
the true incidence of delirium in psychotic patients will not be known. The
suggested causal mechanism of delirium in psychosis is sleep disruption. Sleep is
essential for maintenance of memory circuits, which otherwise suffer progressive
synaptic weakening due to molecular turnover. When sleep is disrupted, memory
circuits deteriorate, and subsequent activation of incompetent circuits can
generate psychotic symptoms. Induction of physiologically normal sleep would
therefore be expected to produce significant clinical improvement in patients
with psychotic symptoms. Furthermore, the ‘anti-delirium’ action of
electroconvulsive therapy may account for its effectiveness in alleviating a wide
range of psychiatric and neurological pathologies.
PMID: 11863395 [PubMed – indexed for MEDLINE] 124. Psychiatry Res. 2001 Nov 1;104(2):183-90.

Electroconvulsive therapy in adolescents with mood disorder: patients’ and
parents’ attitudes.

Taieb O, Flament MF, Corcos M, Jeammet P, Basquin M, Mazet P, Cohen D.

Department of Child and Adolescent Psychopathology, Groupe Hospitalier
Pitié-Salpétrière, 43-87 Boulevard de l’Hôpital, 75013 Paris, France.

The aim of the study was to assess retrospectively patients’ and parents’
experiences and attitudes towards the use of electroconvulsive therapy (ECT) in
adolescence. The experiences of subjects (n=10) who were administered ECT in
adolescence for a severe mood disorder and their parents (n=18) were assessed
using a semi-structured interview after a mean of 4.5 years (range, 19 months to
9 years). Their attitudes were mostly positive and ECT was considered a helpful
treatment. Concerns were frequently expressed, probably because ECT was not fully
understood by the patients and their families. Most complaints were of transitory
memory impairment. The parents were satisfied with the consent procedure, while
all but one patient did not remember the consent procedure. We concluded that,
despite negative views about ECT in public opinion, adolescent recipients and
their parents shared overall positive attitudes towards the use of ECT in this
age range.
PMID: 11711171 [PubMed – indexed for MEDLINE] 125. J Affect Disord. 2001 Oct;66(2-3):237-45.

“Side effects” of ECT are mainly depressive phenomena and are independent of age.

Brodaty H, Berle D, Hickie I, Mason C.

School of Psychiatry, University of New South Wales, Sydney, Australia.

BACKGROUND: The aetiology of reported side effects of electroconvulsive therapy
(ECT) is unclear. We examined the interaction of depression and age on adverse
neuropsychological and putative side effects of ECT. METHOD: Inpatients (N=81;
median age 70 years) with major depression were assessed prospectively pre-ECT,
immediately post-ECT and 1-3 years later. Patients were administered the Hamilton
Rating Scale for Depression (HRSD), the Global Assessment of Functioning scale
(GAF) and neuropsychological tests from the Wechsler Memory Scale. Side effects
and total burden scores were rated pre- and post-treatment. RESULTS: HRSD and GAF
scores improved with treatment after ECT, but the prevalence and total burden of
side effects were unchanged. Side effect burden was related to depression level
before and after ECT. Improvement in depression correlated with reduction in side
effect burden. There was a significant decline in side effect burden after
controlling for change in depression. Patients’ scores on neuropsychological
measures did not appear to change after ECT or between pre-ECT and follow-up.
Re-analysis, allowing for age, chronicity of depression, medication use and
development of dementia, did not alter the findings. LIMITATIONS: lack of a
control group, lack of information on ECT technique, incomplete data sets and
limited neuropsychological testing. CONCLUSIONS: ECT, an effective treatment for
depression, does not cause significant side effects or neuropsychological
impairment, which are more likely to be depressive phenomena. ECT appears to be
safe for old (> or =65 years) and very old (> or =75 years) patients, who do not
appear to be more susceptible to adverse effects.
PMID: 11578677 [PubMed – indexed for MEDLINE] 126. Biol Psychiatry. 2001 Sep 1;50(5):331-6.

Cortisol levels predict cognitive impairment induced by electroconvulsive

Neylan TC, Canick JD, Hall SE, Reus VI, Sapolsky RM, Wolkowitz OM.

Department of Psychiatry, University of California, San Francisco, CA 94121, USA.

BACKGROUND: Elevated glucocorticoids may increase the vulnerability of the brain
to the adverse effects of repeated seizures. This study tested the hypothesis
that higher ambient cortisol levels would predict increased cognitive impairment
in depressed patients subsequent to receiving electroconvulsive therapy (ECT) for
major depression. METHODS: Sixteen subjects provided three samples of saliva the
day before receiving unilateral nondominant ECT. Measures of mood, global
cognitive functioning, attention, executive function, verbal and visuospatial
memory, and visuospatial processing speed were obtained 1 day before the first
ECT and 1 day after the sixth ECT treatment. The relationship between basal
salivary cortisol obtained before the first ECT treatment and the change score of
each cognitive measure after the sixth ECT treatment was examined and tested with
Pearson correlation coefficients. RESULTS: Electroconvulsive therapy treatments
delivered over 2 weeks resulted in a significant improvement in mood and a
decline in most measures of cognitive performance. Elevated basal cortisol was
associated with a greater decline in performance of executive function,
visuospatial processing speed, and verbal memory. CONCLUSIONS: Although this
study is limited by the small number of subjects and the high number of
comparisons, all significant correlations were consistent with the hypothesis
that elevated cortisol predicts a greater degree of ECT-induced cognitive
PMID: 11543735 [PubMed – indexed for MEDLINE] 127. J ECT. 2001 Sep;17(3):170-4.

Impact of maintenance ECT on concentration and memory.

Datto CJ, Levy S, Miller DS, Katz IR.

Hospital of the University of Pennsylvania and Friends Hospital, Philadelphia,
Pennsylvania 19104, USA.

INTRODUCTION: With the increased administration of outpatient electroconvulsive
therapy (ECT), it is important to develop methods for monitoring patients for
adverse effects of treatment. This pilot study was designed to evaluate the
utility of using telephone assessments to determine whether patents receiving
maintenance ECT (MECT) experience cognitive deficits related to individual
treatments. METHOD: Patients were recruited from an existing population of
outpatients receiving MECT. The consenting patients were called on three
occasions and given a battery of telephone cognitive assessments including
Orientation-Memory-Concentration, Buschke Selective Reminding, Verbal Fluency,
“World” Backwards, Serial Sevens, and Wechsler Logical Memory. The occasions for
the telephone interviews were the day before ECT, the day after a treatment, and
a week later. RESULTS: Sixteen patients completed the study. The correlation
between baseline and time 3 ranged from 1.00 for spelling “world” backward to
0.509 for Verbal Fluency Category, indicating considerable variability in
test-retest reliability. One test, Verbal Fluency Category, showed group level
effects, with decrements in performance the day after a treatment. One of the 16
patients showed global cognitive deficits the day after a treatment. DISCUSSION:
The pilot results suggest that telephone assessment may be a useful approach for
monitoring patients receiving outpatient ECT. Monitoring may serve to guide
clinicians in advising individuals and their caregivers about the return to
activities after an individual treatment. Overall these findings support the
tolerability of MECT.
PMID: 11528306 [PubMed – indexed for MEDLINE] 128. Nervenarzt. 2001 Sep;72(9):661-76.

[Use of electroconvulsive therapy in psychiatry] [Article in German]

Frey R, Schreinzer D, Heiden A, Kasper S.

Klinische Abteilung für Allgemeine Psychiatrie, Universitätsklinik für
Psychiatrie, Währinger Gürtel 18-20, A-1090 Wien.

Electroconvulsive therapy (ECT) has antidepressive and antipsychotic effects.
Since being introduced in Italy in 1938, its mode of action has still not been
clarified. Treatment modalities have changed in many ways. ECT, in which a
generalized epileptic seizure is provoked by electrical stimulation of the brain,
is performed under short intravenous anesthesia and muscle relaxation.
Considering careful previous clinical examination and anesthesiological and
internal counterindications, ECT is a very safe form of treatment. Single cases
of persisting memory impairment were described after the formerly common
bilateral sinus wave stimulation. However, recent developments such as brief
pulse stimulation, unilateral electrode placement, and individual stimulus
titration (on the basis of EEG monitoring) make memory impairment as a
consequence of ECT a rare event which mostly remits completely in 4-8 weeks.
Today, ECT is performed mainly in patients suffering from severe,
therapy-resistant affective or schizophrenic disorders. Pernicious catatonia and
the neuroleptic malignant syndrome are emergency indications. Adequate ECT
treatment requires a series of 6-12 individual sessions (every second or third
day). In therapy-resistant depression, for which the greatest number of data are
available, the response rate lies between 50 and 60%. This has been confirmed by
a descriptive analysis of all ECT treatments at the Department of Psychiatry,
University of Vienna, between 1994 and 2000. There is a need for controlled
studies on continuation therapy subsequent to successful ECT.
PMID: 11572099 [PubMed – indexed for MEDLINE] 129. J ECT. 2001 Jun;17(2):129-35.

Subtypes of memory dysfunction associated with ECT: characteristics and
neurobiological bases.

Rami-Gonzalez L, Bernardo M, Boget T, Salamero M, Gil-Verona JA, Junque C.

Department of Psychiatry and Clinical Psychobiology, University of Barcelona,

Electroconvulsive therapy (ECT) is an effective treatment for a variety of
psychiatric syndromes. However, one of its adverse secondary effects is
neurocognitive dysfunction. The aim of this paper is to review different subtypes
of memory dysfunction associated with ECT from a neuropsychological perspective.
Declarative memory is clearly impaired after ECT. Immediate memory, however, is
broadly preserved. Few studies have addressed procedural and incidental memory.
Selective memory is impaired, probably due to the disruption of specific brain
regions. Some of the possible neurobiological bases of ECT memory dysfunction are
discussed in this paper. Synaptic plasticity, the cerebral neurotransmission
system, and cerebral metabolism are examined in relation to the dysfunction and
subsequent recovery of each memory subtype.
PMID: 11417924 [PubMed – indexed for MEDLINE] 130. J Neuropsychiatry Clin Neurosci. 2001 Spring;13(2):187-96.

Prevalence, clinical manifestations, etiology, and treatment of depression in
Parkinson’s disease.

Slaughter JR, Slaughter KA, Nichols D, Holmes SE, Martens MP.

Department of Psychiatry and Neurology, University of Missouri School of
Medicine, Columbia 65212, USA.

To determine the extent to which depression complicates Parkinson’s disease (PD),
the authors analyzed the literature on depression in PD in order to report on its
prevalence, clinical manifestations, and treatment. By means of MEDLINE
literature searches, the analysis focused on 45 PD depression studies conducted
from 1922 through 1998. The results indicate that the prevalence of depression is
31% for all PD patients. The clinical manifestations of PD depression include
apathy, psychomotor retardation, memory impairment, pessimism, irrationality, and
suicidal ideation without suicidal behavior. PD depression is effectively treated
with a variety of antidepressants, most commonly at present the selective
serotonin reuptake inhibitors. Anecdotal evidence supports the use of sertraline
to treat PD depression.
PMID: 11449025 [PubMed – indexed for MEDLINE] 131. Cogn Affect Behav Neurosci. 2001 Mar;1(1):3-9.

Recognition memory in amnesia: effects of relaxing response criteria.

Verfaellie M, Giovanello KS, Keane MM.

Boston VA Healthcare System, Boston University School of Medicine, Boston,
Massachusetts, USA.

In two experiments, using the remember/know paradigm, we examined whether
recognition memory in amnesic patients can be improved by instructing patients to
relax their response criterion. Experiment 1 was modeled after a study by
Dorfman, Kihlstrom, Cork, and Misiaszek (1995), in which direct instructions to
respond more leniently led to an increase in recognition accuracy in patients
with ECT-induced amnesia. We failed to extend this finding to patients with
global amnesia, but the manipulation was unsuccessful in control subjects as
well. In Experiment 2, response criterion was manipulated indirectly by providing
information about the alleged base rate of study items on the recognition test.
This manipulation led to a criterion shift in control subjects and enhanced
discriminability in amnesic patients. Analysis of “remember” and “know” responses
suggests that improved accuracy in amnesia was associated with enhanced
familiarity-based recognition.
PMID: 12467099 [PubMed – indexed for MEDLINE] 132. J Affect Disord. 2001 Mar;63(1-3):1-15.

Convulsive therapy: a review of the first 55 years.

Fink M.

Departments of Psychiatry and Neurology, Long Island Jewish-Hillside Medical
Center, Glen Oaks, Long Island, NY 11004, USA.

Convulsive therapy was introduced to psychiatric practice in 1934. It was widely
hailed as an effective treatment for schizophrenia and quickly recognized as
equally effective for the affective disorders. Like other somatic treatments, it
was replaced by psychotropic drugs introduced in the 1950s and 1960s. But two
decades later, ECT was recalled to treat pharmacotherapy-resistant cases. Avid
searches to optimize seizure induction and treatment courses, to reduce risks and
fears, to broaden the indications for its use, and to understand its mechanism of
action followed. Unlike other medical treatments, however, these searches were
severely impeded by a vigorous antipsychiatry movement among the public and
within the profession. ECT is effective in the treatment of patients with major
depression, delusional depression, bipolar disorder, schizophrenia, catatonia,
neuroleptic malignant syndrome, and parkinsonism, and this breadth of action is
both remarkable and unique. ECT is a safe treatment. No age or systemic condition
bars its use. Its major limitations are the high relapse rates and the occasional
profound effects on memory and recall that mar its success. Experiments to
sustain its benefits with medications and with continuation ECT are underway. Its
mode of action remains a mystery and this puzzle is an unappreciated challenge.
The full impact of this intervention is yet to be felt.
PMID: 11246075 [PubMed – indexed for MEDLINE] 133. J ECT. 2001 Mar;17(1):60-4.

Extended continuation and maintenance ECT for long-lasting episodes of major

Fox HA.

Department of Psychiatry, Cornell University Medical College, New York, New York
10021, USA.

While most major depressive episodes are relatively short lasting, a substantial
minority of patients with severe mood disorders respond poorly to available
treatments and remain ill for extended periods of time. The possible role of
continuation and maintenance electroconvulsive therapy (ECT) in the management of
such patients has not been clearly established. Three patients are reported whose
long-lasting, relatively medication refractory episodes of major depression were
treated with ECT for both acute and continuation and maintenance purposes.
Although relapses occurred despite treatment, the frequency, severity, and
duration of relapses were apparently diminished by ECT. Relapses occurred with
diminishing frequency over the course of individual episodes, and were typically
reversed by three or four closely spaced ECT treatments. No medical complications
occurred. While complaints of memory difficulty were common, Mini-Mental Status
Examinations 6 weeks after ECT were unimpaired. Continuation and maintenance ECT
appears to be a safe and effective treatment modality for long-lasting episodes
of major depression. Recommendations for clinical management are proposed.
PMID: 11281519 [PubMed – indexed for MEDLINE] 134. Eur Psychiatry. 2001 Feb;16(1):75-8.

Verbal perseveration after right-unilateral ECT.

Adler G, Achenbach C.

Day-Clinic for the Elderly, Central Institute of Mental Health, J5, 68159,
Mannheim, Germany.

After electroconvulsive therapy (ECT), many patients experience a decrement in
their mnestic capacity. We studied episodic memory in eight severely depressed
patients treated with a course of right-unilateral ECT. For this purpose, a
testing instrument was constructed by the authors. It was made of paper cards
that held four pieces of information, namely a word, a number, a figure, and the
color of the card. One of the cards was presented to the patients and the
respective information was asked for on the subsequent day. Patients were tested
every morning during the first two weeks of the ECT course. About half of the
responses were correct. Patients did best in recalling the color; they did worst
in recalling the number. Seven of the patients showed verbal perseverations. This
is in accordance with the literature on perseveration in patients with neurologic
deficits, especially in proactive-inhibitory tasks. Perseveration may be
attributed to a deficit in selective attention, producing an arousal of
irrelevant cues.
PMID: 11246297 [PubMed – indexed for MEDLINE] 135. J ECT. 2000 Dec;16(4):370-9.

Efficacy and cognitive effects of right unilateral electroconvulsive therapy.

Ng C, Schweitzer I, Alexopoulos P, Celi E, Wong L, Tuckwell V, Sergejew A, Tiller

The Melbourne Clinic, Department of Psychiatry, University of Melbourne,
Richmond, Victoria, Australia.

The efficacy, memory, and cognitive effects of right unilateral (RUL)
electroconvulsive therapy (ECT) at 2.5 times threshold in 32 inpatients with
moderate to severe major depressive disorder were evaluated at baseline, during
the course of treatment, and 1 month after treatment. Neuropsychological
assessment included the Randt Memory Test, Personal Memory Test, short-version
Wechsler Adult Intelligence Scale-Revised, and Self-Rating Scale of Memory
Functions. At the treatment end point, although the Hamilton Depression Rating
Scale mean score was decreased by 54.2%. the response rate of 2.5 times threshold
RUL ECT using stringent criteria was only 31.2%. Treatment was associated with
significant anterograde memory impairment in the short term. Mean total scores of
the Randt Memory Test and Personal Memory Test were decreased from baseline by
14.8% and 32.5%, respectively, after six sessions of ECT. These memory deficits
were significantly improved by the 1 month follow-up examination. Subjective
memory scores increased consistently during treatment, correlating with
improvements in mood. No adverse effects on nonmemory cognition were found.
Although RUL ECT at 2.5 times threshold is not associated with marked or
persistent cognitive disturbances, its efficacy may be insufficient in clinical
PMID: 11314875 [PubMed – indexed for MEDLINE] 136. Nat Rev Neurosci. 2000 Dec;1(3):214-6.

Memory involves far more than ‘consolidation’.

Miller RR, Matzel LD.

Department of Psychology, State University of New York at Binghamton, Binghamton,
New York 13902-6000, USA.

The observation that retrieval returns a stable memory into a labile state cannot
be readily explained by any simple version of consolidation theory. This finding
has been interpreted as evidence for the need to reconsolidate a memory after
reactivating it. However, as we discuss in this commentary, other behavioural
observations indicate that even this modification to consolidation theory may be
insufficient to describe the dynamic properties of memory.
PMID: 11257911 [PubMed – indexed for MEDLINE] 137. J Affect Disord. 2000 Nov;60(2):101-11.

A prospective follow-up study of ECT outcome in older depressed patients.

Brodaty H, Hickie I, Mason C, Prenter L.

School of Psychiatry, University of New South Wales, Sydney, Australia.

BACKGROUND: This study examined the relationship between age and outcome of
electroconvulsive therapy (ECT). METHOD: This was a naturalistic, prospective
follow-up of 81 consecutive in-patients with primary major depression. ECT
outcome was compared for three age groups – under 65, 65-74 and 75 years and over
– on the Hamilton Rating Scale for Depression (HRSD), Global Assessment of
Functioning scale (GAF) and clinical outcome rating scale. Assessments were
performed pre-ECT, immediately post-ECT, 1-3 years later and, for patients
suspected of having dementia, 5 years later. RESULTS: At post-ECT and follow-up,
improvement on HRSD and clinical outcome ratings were comparable for patients in
the three age groups. Improvements on GAF were also comparable post-ECT, but not
between post-ECT and follow-up. At follow-up, 35.7% of the oldest group had
dementia. Importantly, patients who did and did not develop dementia were
clinically indistinguishable prior to ECT. The number and severity of common
adverse events were similar pre- and post-ECT and were not associated with age.
CONCLUSIONS: Depressive outcome and adverse effects of ECT are largely
independent of age. Older patients receiving ECT appear to have a higher risk of
developing dementia, possibly underpinned by cerebrovascular disease.
PMID: 10967369 [PubMed – indexed for MEDLINE] 138. Arch Gen Psychiatry. 2000 Oct;57(10):937-43.

The hippocampus in patients treated with electroconvulsive therapy: a proton
magnetic resonance spectroscopic imaging study.

Ende G, Braus DF, Walter S, Weber-Fahr W, Henn FA.

NMR Research in Psychiatry, Central Institute of Mental Health, Postfach 1221 20,
D-68072 Mannheim, Germany.

BACKGROUND: We monitored the effect of electroconvulsive therapy (ECT) on the
nuclear magnetic resonance-detectable metabolites N-acetylaspartate, creatine and
phosphocreatine, and choline-containing compounds in the hippocampus by means of
hydrogen 1 magnetic resonance spectroscopic imaging. We hypothesized that if
ECT-induced memory deterioration was associated with neuronal loss in the
hippocampus, the N-acetylaspartate signal would decrease after ECT and any
increased membrane turnover would result in an increase in the signal from
choline-containing compounds. METHODS: Seventeen patients received complete
courses of ECT, during which repeated proton magnetic resonance spectroscopic
imaging studies of the hippocampal region were performed. Individual changes
during the course of ECT were compared with values obtained in 24 healthy control
subjects and 6 patients remitted from major depression without ECT. RESULTS: No
changes in the hippocampal N-acetylaspartate signals were detected after ECT. A
significant mean increase of 16% of the signal from choline-containing compounds
after 5 or more ECT treatments was observed. Despite the mostly unilateral ECT
application (14 of 17 patients), the increase in the choline-containing compound
signal was observed bilaterally. Lactate or elevated lipid signals were not
detected. All patients showed clinical amelioration of depression after ECT.
CONCLUSIONS: Electroconvulsive therapy is not likely to induce hippocampal
atrophy or cell death, which would be reflected by a decrease in the
N-acetylaspartate signal. Compared with an age-matched control group, the
choline-containing compounds signal in patients with a major depressive episode
was significantly lower than normal, before ECT and normalized during ECT.
PMID: 11015811 [PubMed – indexed for MEDLINE] 139. Neuropsychiatry Neuropsychol Behav Neurol. 2000 Oct;13(4):246-53.

Learning and memory in bipolar and unipolar major depression: effects of aging.

Burt T, Prudic J, Peyser S, Clark J, Sackeim HA.

Department of Biological Psychiatry, New York State Psychiatric Institute,
College of Physicians and Surgeons of Columbia University, New York 10032, USA.

OBJECTIVE: The goal of this study was to examine the effects of aging on
neuropsychological functions in bipolar and unipolar major depression.
BACKGROUND: Earlier studies suggested that neurocognitive deficits in mood
disorder patients correlate with duration and severity of illness and also that
bipolar disorder has a more virulent course than unipolar disorder. We
hypothesized that elderly patients with bipolar disorder will demonstrate greater
neurocognitive dysfunction than young patients with bipolar disorder and elderly
patients with unipolar disorder. METHOD: A battery of tests of general
intelligence and learning and memory was administered to 79 inpatients with major
depression referred for electroconvulsive therapy. With patients 60 years of age
and older defined as elderly, there were 29 young and 24 elderly unipolar
patients and 13 young and 13 elderly bipolar patients. RESULTS: Unipolar and
bipolar patients did not differ in measures of general intelligence or global
cognitive status. Generally, across tests of memory, young bipolar patients
exhibited the best performance and elderly bipolar patients exhibited the poorest
performance. CONCLUSIONS: The results suggest that over the course of their
illness, patients with bipolar disorder experience greater deterioration in
memory functions than patients with unipolar disorder. Longitudinal studies are
required to support the preliminary findings of this cross-sectional study.
PMID: 11186160 [PubMed – indexed for MEDLINE] 140. Int J Geriatr Psychiatry. 2000 Aug;15(8):729-35.

The benefits and risks of ECT for patients with primary dementia who also suffer
from depression.

Rao V, Lyketsos CG.

Neuropsychiatry and Memory Group, Department of Psychiatry and Behavioral
Sciences, School of Medicine, The John Hopkins University, Baltimore, MD 21287,

Comment in:
Int J Geriatr Psychiatry. 2001 Sep;16(9):919-20.

BACKGROUND: Major depression afflicts 20-25% of patients with dementia. Of these,
about a third do not improve with antidepressant therapy and may be suitable
candidates for electronconvulsive treatment (ECT). However, the use of ECT is
dementia patients is concerning due to possible adverse effects on memory and
cognition. Outcome studies of ECT in patients with primary dementia and
depression are very rare. OBJECTIVE: To determine the effectiveness and
complications of ECT treatment for depression in dementia. METHOD: A chart review
was conducted of all 31 patients wit ha discharge diagnosis of ‘Dementia with
depression’ treated with ECT at the Johns Hopkins Hospital, over a five-year
period. Admission and discharge ratings were made on the Mini-Mental State
Examination (MMSE) and the Montgomery-Asberg Depression Rating Scale (MADRS) as
part of the clinical routine. RESULTS: All patients suffered from dementia: 55%
had vascular dementia, 13% Alzheimer’s disease, and 32% degenerative dementia of
uncertain etiology. The admission MADRS mean score was 27.5 (SD 8.1) and the MMSE
mean score was 18.8 (SD 5. 5). The patients received between 1 and 23 ECT
treatments (mean 9, SD 5.7). At discharge, there was a statistically significant
mean decline on the MADRS of 12.28 points (p<0.01). Forty percent had scores less
than 10 (normal) on the MADRS. While 49% of patients developed delirium, by
discharge there was also a significant mean increase (improvement) in MMSE of
1.62 points (p<0.02). CONCLUSIONS: ECT is an effective treatment for depression
in dementia, leading to improvements in both mood and cognition. Multiple ECT
treatments may be necessary before a significant improvement in mode is achieved.
PMID: 10960885 [PubMed – indexed for MEDLINE] 141. Arch Gen Psychiatry. 2000 Jun;57(6):581-90.

The effects of electroconvulsive therapy on memory of autobiographical and public

Lisanby SH, Maddox JH, Prudic J, Devanand DP, Sackeim HA.

Department of Biological Psychiatry, New York State Psychiatric Institute, New
York 10032, USA.

Comment in:
Arch Gen Psychiatry. 2000 Jun;57(6):591-2.

BACKGROUND: Retrograde amnesia is the most persistent cognitive adverse effect of
electroconvulsive therapy (ECT); however, it is not known whether ECT has
differential effects on autobiographical vs impersonal memories. This study
examined the short- and long-term effects of differing forms of ECT on memory of
personal and impersonal (public) events. METHODS: Fifty-five patients with major
depression were randomly assigned to right unilateral (RUL) or bilateral (BL)
ECT, each at either low or high electrical dosage. The Personal and Impersonal
Memory Test was administered by blinded raters at baseline, during the week after
ECT, and at the 2-month follow-up. Normal controls were tested at matched
intervals. RESULTS: Shortly after ECT, patients recalled fewer events and event
details than controls, with the deficits most marked for impersonal compared with
personal events. Bilateral ECT caused more marked amnesia for events and details
than RUL ECT, and especially for impersonal memories. These effects were
independent of electrical dosage and clinical outcome. At the 2-month follow-up,
patients had reduced retrograde amnesia, but continued to show deficits in
recalling the occurrence of impersonal events and the details of recent
impersonal events. CONCLUSIONS: The amnestic effects of ECT are greatest and most
persistent for knowledge about the world (impersonal memory,) compared with
knowledge about the self (personal memory), for recent compared with distinctly
remote events, and for less salient events. Bilateral ECT produces more profound
amnestic effects than RUL ECT, particularly for memory of impersonal events.
PMID: 10839336 [PubMed – indexed for MEDLINE] 142. J ECT. 2000 Jun;16(2):144-56.

Herbal treatments for ECS-induced memory deficits: a review of research and a
discussion on animal models.

Andrade C, Sudha S, Venkataraman BV.

Department of Psychopharmacology, National Institute of Mental Health and
Neurosciences, Bangalore, India.

During the last decade the use of herbal medicinal substances in the attenuation
of anterograde and retrograde amnesia induced by electroconvulsive shock (ECS)
has been studied using animal research. We will discuss the background of herbal
medicine in India, review the research findings on herbal medicines for
ECS-induced amnestic deficits, and examine the applications and limitations of
animal models in this context. We will focus on our own research and insights,
with particular emphasis on practical issues.
PMID: 10868324 [PubMed – indexed for MEDLINE] 143. J ECT. 2000 Jun;16(2):133-43.

Electroconvulsive therapy and memory loss: a personal journey.

Donahue AB.

Comment in:
J ECT. 2000 Jun;16(2):87-96.
J ECT. 2002 Jun;18(2):71-3.

The cause for the significant gap between research and anecdotal evidence
regarding the extent of some memory loss after electroconvulsive therapy (ECT)
has never been adequately explained. A patient’s development of awareness and
self-education about her severe side effects from ECT raises questions regarding
many current assumptions about memory loss. ECT-specific studies, which conclude
that side effects are short term and narrow in scope, have serious limitations,
including the fact that they do not take into account broader scientific
knowledge about memory function. Because of the potential for devastating and
permanent memory loss with ECT, informed consent needs significant enhancement
until advancing research on both improved techniques and on better predictive
knowledge regarding memory loss progresses to making a greater impact on clinical
applications. Follow-up care and education in coping skills need to be a regular
part of ECT practice when patients do experience severe effects.
PMID: 10868323 [PubMed – indexed for MEDLINE] 144. J ECT. 2000 Jun;16(2):121-32.

Subjective memory complaints: a review of patient self-assessment of memory after
electroconvulsive therapy.

Prudic J, Peyser S, Sackeim HA.

Department of Biological Psychiatry, New York State Psychiatric Institute, NY
10032, USA.

Comment in:
J ECT. 2000 Jun;16(2):87-96.

Interest in patients’ subjective complaints about the adverse cognitive effects
of electroconvulsive therapy (ECT) spans several decades. This article reviews
the major areas that have been examined in relation to patients’ subjective
assessment of memory function: 1) technical aspects in the administration of ECT;
2) objective tests of cognitive function; and 3) clinical state. For the most
part, subjective assessments of memory following ECT have relied on a single
instrument, the Squire Subjective Memory Questionnaire (SSMQ). While older
reports of the impact of the technical aspects of ECT on subjective memory
assessment following ECT suggest a detectable negative influence with certain
forms of treatment, most recent studies indicate that subjective memory improves
following ECT. This shift in findings may be due to the change in practice from
sine wave to brief-pulse ECT. While the impact of ECT on objective tests of
memory is clear and reproducible, the relationship of objective findings to
subjective memory assessment appears to be weak. Instead, subjective reports of
cognitive function are strongly influenced by mood state. Current batteries of
objective tests of memory may not include components that are most affected in
reports about subjective memory. In addition, the literature mainly reports group
effects, and sample sizes have been small. We lack data on the number of
individuals who believe ECT has had a markedly negative effect on memory
functioning, and on the characteristics of memory function in this subgroup of
patients who complain of severe impairment. Furthermore, there is a paucity of
information relating patient characteristics to subjective memory outcomes with
PMID: 10868322 [PubMed – indexed for MEDLINE] 145. J ECT. 2000 Jun;16(2):110-20.

Electrophysiological correlates of the adverse cognitive effects of
electroconvulsive therapy.

Sackeim HA, Luber B, Moeller JR, Prudic J, Devanand DP, Nobler MS.

Department of Biological Psychiatry, New York State Psychiatric Institute, New
York 10032, USA.

Resting state, eyes closed, 19-lead EEG recordings were obtained at pre-ECT
baseline and just prior to penultimate treatment and during the week following
the ECT course in 59 patients with major depression. Patients had been randomized
to ECT conditions that varied in electrode placement and stimulus intensity. The
EEG data were submitted to power spectral analysis, and global and topographic
effects were characterized for the delta and theta frequency bands. Relations
between the EEG changes and scores on three cognitive measures were examined. The
period of disorientation immediately following RUL ECT was associated with an
accentuation of delta power in anterior frontal and temporal regions. Across the
electrode placements, increased theta activity in left frontotemporal regions was
associated with longer recovery of orientation. Post-ECT decrements in global
cognitive status, as assessed by the modified Mini-Mental State exam, were
associated with a greater increase in delta relative to theta power, globally
across the cortex. The magnitude of retrograde amnesia for autobiographical
events correlated with increased theta activity in left frontotemporal regions.
The findings suggest that distinct neurophysiological changes subserve the
therapeutic and adverse cognitive effects of ECT. Postictal disorientation and
post-ECT retrograde amnesia appear to share a common physiological substrate.
PMID: 10868321 [PubMed – indexed for MEDLINE] 146. J ECT. 2000 Jun;16(2):97-109.

Balancing speed of response to ECT in major depression and adverse cognitive
effects: role of treatment schedule.

Shapira B, Tubi N, Lerer B.

Depression Unit, Herzog Hospital, Jerusalem, Israel.

Schedule of administration (number of ECT per week and total number of treatments
in the course) is one of a number of factors that may significantly influence the
degree of cognitive impairment induced by ECT. We examined the effect of twice
(ECT x 2) versus three times weekly (ECT x 3) bilateral ECT on cognitive
function, particularly memory, in patients with major depression. Two studies
were conducted, both double blind and controlled by the administration of
simulated ECT (anesthesia and muscle relaxant only with no electrical
stimulation). The results of these studies showed that the antidepressant effect
of the two schedules, when assessed at the end of the ECT course, was equal.
Speed of response was significantly greater with ECT x 3 but this schedule
induced more severe memory impairment, even when the number of ECT in the series
was not significantly different between the two groups. These findings are in
general accordance with other studies that were similar in design although not as
rigorously controlled. They support the conclusion that ECT x 2 is the more
appropriate schedule for regular clinical practice unless speed of response is an
overriding concern. In an era when patients administered ECT tend to be older and
are more likely to manifest cognitive impairment for other reasons, choice of
schedule is of particular relevance along with other factors such as electrode
placement and stimulus intensity that influence ECT-induced cognitive impairment.
PMID: 10868320 [PubMed – indexed for MEDLINE] 147. Arch Gen Psychiatry. 2000 May;57(5):438-44.

Titrated moderately suprathreshold vs fixed high-dose right unilateral
electroconvulsive therapy: acute antidepressant and cognitive effects.

McCall WV, Reboussin DM, Weiner RD, Sackeim HA.

Department of Psychiatry, Wake Forest University School of Medicine,
Winston-Salem, NC 27157, USA.

Comment in:
Arch Gen Psychiatry. 2000 May;57(5):445-6.
Arch Gen Psychiatry. 2001 Jun;58(6):607.
Arch Gen Psychiatry. 2001 Jun;58(6):607-9.

BACKGROUND: The antidepressant and cognitive side effects of right unilateral
(RUL) electroconvulsive therapy (ECT) are reported to depend on the magnitude of
the electrical stimulus relative to the seizure threshold. The stimulus doses
explored in previous clinical trials of RUL ECT have generally been limited to 1
to 2.5 times the convulsive threshold and the antidepressant efficacy has been
low compared with bilateral (BL) ECT. The present study compares the
antidepressant and cognitive side effects of 2 RUL dosing strategies: titrated
moderately suprathreshold and fixed high dose. METHODS: Seventy-two adult
patients with major depression were randomized to either titrated RUL ECT at 2.25
times initial seizure threshold (mean dose, 136 millicoulombes [mC]), or RUL ECT
at a fixed dose of 403 mC. Primary outcome measures were antidepressant response
and cognitive status 1 or 2 days after the course of ECT. RESULTS: The 2
treatment groups were comparable in demographic and clinical characteristics
prior to ECT. Both groups received a mean of 5.7 sessions of RUL ECT. Patients
receiving fixed-dose ECT were more likely to have an antidepressant response at
the end of the protocol (n = 49 [67%]) compared with those receiving titrated
dosing (n = 28 [39%]). Furthermore, the likelihood of both antidepressant
response and cognitive deficits increased as stimulus dose increased relative to
initial seizure threshold, up through 8 to 12 times the threshold. CONCLUSIONS:
The antidepressant efficacy and cognitive side effects of RUL ECT are dependent
on the magnitude of the stimulus dose relative to the seizure threshold, and a
dose-response relationship extends through at least 12 times the seizure
PMID: 10807483 [PubMed – indexed for MEDLINE] 148. Arch Gen Psychiatry. 2000 May;57(5):425-34.

A prospective, randomized, double-blind comparison of bilateral and right
unilateral electroconvulsive therapy at different stimulus intensities.

Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, Fitzsimons L,
Moody BJ, Clark J.

Department of Biological Psychiatry, New York State Psychiatric Institute, NY
10032, USA.

Comment in:
Arch Gen Psychiatry. 2001 Jun;58(6):607-9.
Arch Gen Psychiatry. 2000 May;57(5):445-6.
Arch Gen Psychiatry. 2001 Jun;58(6):607.

BACKGROUND: Controversy persists about the use of right unilateral (RUL) and
bilateral (BL) electroconvulsive therapy (ECT). While RUL ECT results in less
severe short-term and long-term cognitive effects, there is concern that it is
less efficacious than BL ECT. METHODS: In a double-blind study, 80 depressed
patients were randomized to RULECT, with electrical dosages 50%, 150%, or 500%
above the seizure threshold, or BL ECT, with an electrical dosage 150% above the
threshold. Depression severity and cognitive functioning were assessed before,
during, immediately after, and 2 months after ECT. Compared with baseline,
responders had at least a 60% reduction in symptom scores 1 week after ECT, and
were monitored for relapse for 1 year. RESULTS: High-dosage RUL and BL ECT were
equivalent in response rate (65%) and approximately twice as effective as
low-dosage (35%) or moderate-dosage (30%) unilateral ECT. During the week after
the randomized phase, BL ECT resulted in greater impairment than any dosage of
unilateral ECT in several measures of anterograde and retrograde memory. Two
months after ECT, retrograde amnestic deficits were greatest among patients
treated with BL ECT. Thirty-three (53%) of the 62 patients who responded to ECT
relapsed, without treatment group differences. The relapse rate was greater in
patients who had not responded to adequate pharmacotherapy prior to ECT and who
had more severe depressive symptoms after ECT. CONCLUSION: Right unilateral ECT
at high dosage is as effective as a robust form of BL ECT, but produces less
severe and persistent cognitive effects.
PMID: 10807482 [PubMed – indexed for MEDLINE] 149. Nihon Shinkei Seishin Yakurigaku Zasshi. 2000 May;20(2):77-9.

[Preliminary report on the efficacy and safety of brief-pulse ECT in depression] [Article in Japanese]

Motohashi N, Takano H, Terada T, Ogawa K, Muramatsu R.

National Center Hospital for Mental, Nervous, and Muscular Disorders, National
Center of Neurology and Psychiatry, Kodaira, Japan.

Because there is no report on the use of brief-pulse devices in Japan, we have
examined the efficacy and safety of brief-pulse electroconvulsive therapy (ECT)
on four treatment-resistant depressive patients (three males and one female, 55.0
+/- 17.8 years of age). The ethical committee of the National Center of Neurology
and Psychiatry approved this study and written informed consent was obtained from
all of the patients. ECT was administered bilaterally twice a week using
atropine, propofol, and succinylcholine (or vecronium) as anesthetic medications.
The Hamilton rating scale for depression scores decreased from 30.5 +/- 11.0 to
14.8 +/- 11.5 following a course of 5-12 treatments. Memory and cognitive
functioning, evaluated using the Mini-Mental State Examination, Short-Memory
Questionnaire and so on, had not changed a week after the last ECT. These results
further support the view that brief-pulse ECT is efficacious and safe for the
treatment of depression.
PMID: 11062865 [PubMed – indexed for MEDLINE] 150. Med Hypotheses. 2000 Apr;54(4):678-83.

Mental malfunction and memory maintenance mechanisms.

Kavanau JL.

Department of Organismic Biology, Ecology and Evolution, University of California
(UCLA), Los Angeles, CA 90095-1606, USA.

Dreams appear to be generated in the process of reinforcing memory circuits of
the brain, as circuits are activated by self-generated electrical slow waves,
with dream contents reflecting information stored in activated circuits. Illusory
dreams and other healthy delirious states appear to occur when activated memory
circuits are incompetent, containing synapses whose efficacies deviate from their
‘dedicated’ values. Organic delirium and some other mental disorders may have
their basis in brain pathologies that alter reinforcing slow waves, causing
synaptic efficacies to depart from dedicated values. Activation of these
incompetent circuits leads to recall of faulty memories–a substrate for
delirium. In treatment of organic delirium by electroconvulsive therapy (ECT),
the electric shock temporarily suppresses abnormal slow-wave regimes, allowing
remedial reinforcement regimes to resume. These restore dedicated synaptic
efficacies, temporarily alleviating the delirium. The action of ECT shocks
appears to parallel closely that of cardiac defibrillating shocks. Greater than
normal amounts of circuit reinforcement protect sensory circuitry in fatal
familial insomnia, and cognitive circuitry in encephalitis lethargica.
PMID: 10859664 [PubMed – indexed for MEDLINE] 151. Am J Psychiatry. 2000 Mar;157(3):460-2.

Absence of cognitive impairment at long-term follow-up in adolescents treated
with ECT for severe mood disorder.

Cohen D, Taieb O, Flament M, Benoit N, Chevret S, Corcos M, Fossati P, Jeammet P,
Allilaire JF, Basquin M.

Department of Child and Adolescent Psychiatry, Groupe Hospitalier
Pitié-Salpétrière, Paris, France.

OBJECTIVE: Cognitive functions of adolescents treated with ECT for mood disorder
were evaluated at long-term follow-up. METHOD: At an average of 3.5 years
(SD=1.7) after the last ECT, 10 subjects treated during adolescence with
bilateral ECT for severe mood disorder completed a clinical and cognitive
evaluation, including the California Verbal Learning Test and Squire’s Subjective
Memory Questionnaire. The same assessments were given to 10 psychiatric
comparison subjects matched for sex, age, and diagnosis. RESULTS: All cognitive
test scores of the patients treated with ECT were similar to those of the
comparison subjects and did not differ from norms from the community. Six of the
10 ECT-treated patients reported having had memory losses immediately after the
ECT course, but only one complained of subjective memory impairment at follow-up.
CONCLUSIONS: The results suggest that adolescents given ECT for severe mood
disorder do not suffer measurable cognitive impairment at long-term follow-up.
PMID: 10698827 [PubMed – indexed for MEDLINE] 152. J Int Neuropsychol Soc. 2000 Mar;6(3):290-8.

Comparison of the serial position effect in very mild Alzheimer’s disease, mild
Alzheimer’s disease, and amnesia associated with electroconvulsive therapy.

Bayley PJ, Salmon DP, Bondi MW, Bui BK, Olichney J, Delis DC, Thomas RG, Thal LJ.

Department of Neurosciences, University of California, San Diego, La Jolla
92093-0948, USA.

Individuals given a series of words to memorize normally show better immediate
recall for items from the beginning and end of the list than for mid-list items.
This phenomenon, known as the serial position effect, is thought to reflect the
concurrent contributions of secondary and primary memory, respectively, to recall
performance. The present study compared the serial position effects produced on
Trial 1 of the California Verbal Learning Test (CVLT) in mildly demented (N = 25;
M MMSE = 20.0) and very mildly demented (N = 25; M MMSE = 25.5) patients with
Alzheimer’s disease (AD), and age- and education-matched normal control (NC)
participants (N = 50). In addition, the serial position effects of the very
mildly demented AD patients were compared to those of patients with a transient,
circumscribed amnesia arising from a prescribed series of electroconvulsive
therapy (ECT) treatments for the relief of depressive illness (N = 11). While the
NC group exhibited the typical serial position effect, AD patients recalled
significantly fewer words than NC participants overall, and exhibited a
significantly reduced primacy effect (i.e., recall of the first 2 list items)
with a normal recency effect (i.e., recall of the last 2 list items). Patients
with circumscribed amnesia due to ECT were as impaired as the very mildly
demented AD patients on most standard CVLT measures of learning and memory, but
exhibited primacy and recency effects, which were within normal limits. These
results suggest that a reduction in the primacy effect, but not the recency
effect, is an early and ubiquitous feature of the memory impairment of AD. It is
not, however, a necessary feature of all causes of memory impairment.
PMID: 10824501 [PubMed – indexed for MEDLINE] 153. Ther Umsch. 2000 Feb;57(2):90-4.

[Electroconvulsive therapy of depressive disorders] [Article in German]

Folkerts H.

Klinik für Psychiatrie und Psychotherapie, Reinhard-Nieter-Krankenhaus,

Electroconvulsive therapy (ECT) is the most effective treatment in all types of
major depression. On the other side ECT has long suffered from controversial
public image, a reputation that has effectively removed it as treatment option
for many patients. Today ECT is an effective and safe treatment for those with
severe mental illness. Electroconvulsive therapy has undergone fundamental
changes since its introduction 65 years ago. It is no longer a memory-modifying,
fearsome treatment pictured in films. Anesthesia, controlled oxygenation, and
muscle relaxation make the ECT so safe that the risks are less as those which
accompany the use of several psychotropic drugs. Indeed, for the elderly, the
systematic ill, and pregnant women, electroconvulsive therapy is a safer
treatment for mental illness than any alternative.
PMID: 10730103 [PubMed – indexed for MEDLINE] 154. Depress Anxiety. 2000;12(3):130-4.

Side effects of electroconvulsive therapy.

Datto CJ.

University of Pennsylvania, 3600 Market St. 7th floor, Philadelphia, PA 19104,

Electroconvulsive therapy is extremely effective and is the fastest acting
antidepressant treatment now available, although not necessarily limited to use
with depression. Despite years of experience with this technique and its
unparalleled successes, patients continue to be affected by mostly transient, but
sometimes impairing side effects from memory problems and cardiovascular changes
associated with ECT treatments. Nausea, headache, muscle aches, and other side
effects that have been referenced in the literature and clinical experience will
also be discussed in this review. Helpful literature with recommendations on
minimizing the risks of these side effects and improving the tolerability of the
electroconvulsive treatments will also be presented.
PMID: 11126187 [PubMed – indexed for MEDLINE] 155. J Child Adolesc Psychopharmacol. 2000 Winter;10(4):269-76.

Cognitive side effects of electroconvulsive therapy in adolescents.

Ghaziuddin N, Laughrin D, Giordani B.

Division of Child and Adolescent Psychiatry, University of Michigan, Ann Arbor
48109-0390, USA.

OBJECTIVE: The primary aim of this study was to determine the presence of
cognitive impairments among adolescents treated with electroconvulsive therapy
(ECT) and whether these deficits would persist several months following the
treatment. METHODS: Retrospective data resulting from standard clinical care of a
convenience sample with naturalistic follow-up were used. Subjects were 16
adolescents (13 females, 3 males; mean age = 15.9 +/- 1.6 years) hospitalized
with a mood disorder (unipolar depression = 14, bipolar depression = 2).
Cognitive tests administered prior to ECT were compared with results at 7.0 +/-
10.3 days following the last treatment and with a second testing at 8.5 +/- 4.9
months after the last treatment. RESULTS: Comparison of pre-ECT and the first
post-ECT testing administered during the first 10 days of the treatment yielded
significant impairments of concentration and attention, verbal- and
visual-delayed recall, and verbal fluency. A complete recovery of these functions
was noted at the second post-ECT testing. There was no deficit in the ability to
problem solve during the initial or the subsequent testing. CONCLUSION: Cognitive
parameters found to be impaired during the first few days of ECT recovered over
several months following the treatment. Therefore, there was no evidence of
long-term damage to concentration, attention, verbal and visual memory, or verbal
fluency. There were no impairments of motor strength and executive processing,
even during the early (within 7-10 days) post-ECT period. These results should be
regarded as preliminary, awaiting confirmation with larger samples.
PMID: 11191687 [PubMed – indexed for MEDLINE] 156. Neuropsychologia. 2000;38(10):1405-14.

The effect of electroconvulsive therapy (ECT) on implicit memory: skill learning
and perceptual priming in patients with major depression.

Vakil E, Grunhaus L, Nagar I, Ben-Chaim E, Dolberg OT, Dannon PN, Schreiber S.

Department of Psychology, Bar-Ilan University, Ramat-Gan, 52900, Israel.

While explicit memory in amnesics is impaired, their implicit memory remains
preserved. Memory impairment is one of the side effects of electroconvulsive
therapy (ECT). ECT patients are expected to show impairment on explicit but not
implicit tasks. The present study examined 17 normal controls and 17 patients
with severe major depressive disorder who underwent right unilateral ECT.
Patients were tested in three sessions: 24-48 hours prior to, 24-48 hours
following the first ECT, and 24-48 hours following the eighth ECT. The controls
were tested in three sessions, at time intervals that paralleled those of the
patients. Implicit memory was tested by the perceptual priming task – Partial
Picture-Identification (PPI). The skill learning task used entailed solving the
Tower of Hanoi puzzle (TOHP). Explicit memory was tested by picture recall from
the PPI task, verbal recall of information regarding the TOHP, and by the Visual
Paired Association (VPA) test. Results showed that explicit questions about the
implicit tasks were impaired following ECT treatment. Patients’ learning ability,
as measured by the VPA task, was only impaired in the first testing session,
prior to ECT treatment, reflecting the effect of depression. In addition, groups
only differed in the first session on the learning rate of the skill learning
task. Perceptual priming was preserved in the patients’ group in all sessions,
indicating that it is resilient to the effect of depression and ECT. The results
are interpreted in terms of the differential effect of depression and ECT on
explicit and implicit memory.
PMID: 10869584 [PubMed – indexed for MEDLINE] 157. J Hist Neurosci. 1999 Dec;8(3):286-92.

Juhn A. Wada and the sodium amytal test in the first (and last?) 50 years.

van Emde Boas W.

Fifty years ago Juhn A. Wada developed the intracarotid amobarbital procedure
(IAP), a test in which first one and then the other cerebral hemisphere is
temporarily anaesthetised through direct intracarotid application of sodium
amytal. The IAP was devised initially as a method to allow unilateral
electroconvulsive shock therapy for psychosis. The method subsequently proved its
value for the lateralisation of language and, following adaption of the test
protocol, for the assessment of memory functions. Thus the IAP became the
standard test in the presurgical evaluation for resective surgical treatment of
medically intractable epilepsy. This paper will briefly review the history of the
IAP, the controversies concerning its current applications and its expected
eventual replacement by less invasive and more easily repeatable methods, notably
functional magnetic resonance imaging.
PMID: 11624159 [PubMed – indexed for MEDLINE] 158. East Afr Med J. 1999 Nov;76(11):644-50.

Naturalistic comparative study of outcome and cognitive effects of unmodified
electro-convulsive therapy in schizophrenia, mania and severe depression in

Ikeji OC, Ohaeri JU, Osahon RO, Agidee RO.

Department of Psychiatry, College of Medicine, University of Ibadan, Nigeria.

BACKGROUND: Although unmodified electro-convulsive therapy (ECT) is widely used
in Nigeria for schizophrenia, mania and severe depression failing to respond to
adequate pharmacotherapy in the short-term, there are no prospective studies on
its efficacy and side effects. OBJECTIVE: To compare the efficacy of
electro-convulsive therapy and standard pharmacotherapy in the treatment of
schizophrenia, mania and severe depression. DESIGN: A prospective open label
study. METHOD: Seventy subjects (mean age, 29.4) with mean duration of illness,
50.6 months, and diagnosis of schizophrenia (37.1%), mania (28.6%), severe
depression (30%) and schizo-affective disorder (4.3%), were assessed pre-ECT and
at seven other intervals in six months, using the Brief Psychiatric Rating Scale
(BPRS), the Mini-Mental State Examination (MMSE) and other cognitive test
batteries. They were compared with a matched group of patients who received only
pharmacotherapy. RESULTS: Although the ECT group had suffered more treatment
resistant disorders, there was full clinical recovery in two months, when all
were discharged. The group had significantly shortened duration of
hospitalisation, after commencement of ECT. Hence ECT facilitated recovery in
this potentially drug treatment resistant psychotic subjects. Although frequency
of complaints of subjective memory difficulty increased during ECT and normalised
at follow up, objective tests showed steady cognitive improvement with clinical
recovery. Complaints of muscle pain (31.4%), post-ECT confusion (15.7%) and
post-ECT headache (20%) in the first week of treatment, were not evident at
follow up. CONCLUSION: Unmodified ECT combined with pharmacotherapy was safe and
effective with non-enduring subjective memory difficulty for this potentially
drug treatment resistant group of psychotic patients.
PMID: 10734527 [PubMed – indexed for MEDLINE] 159. J Geriatr Psychiatry Neurol. 1999 Fall;12(3):107-17.

Brain biochemistry using magnetic resonance spectroscopy: relevance to
psychiatric illness in the elderly.

Moore CM, Frederick BB, Renshaw PF.

Brain Imaging Center, McLean Hospital, Belmont, Massachusetts 02478, USA.

Magnetic resonance spectroscopy (MRS) allows for the noninvasive study of
cerebral biochemistry. It has been used to investigate cerebral metabolic changes
associated with mental illness in vivo and in vitro. In this review, we will
discuss the application of MRS to psychiatric illness in the elderly. Following a
brief description of the basic principles of MRS, the use of phosphorus (31P) and
proton (1H) MRS to enable a better understanding of normal brain aging, dementia
(Alzheimer’s disease, multiple subcortical infarct dementia, Down syndrome,
frontotemporal dementia, vascular dementia, age-associated memory impairment, and
other dementias), major depression, and electroconvulsive therapy is detailed.
PMID: 10593699 [PubMed – indexed for MEDLINE] 160. J Neurosci Res. 1999 Sep 15;57(6):935-40.

Therapeutic and “dose-dependent” effect of repetitive microelectroshock induced
by transcranial magnetic stimulation in Parkinson’s disease.

Mally J, Stone TW.

Department of Neurology, Erszebet Korhaz, Sopron, Hungary.

Transcranial magnetic stimulation (TMS) has been used in the diagnosis of
neurological lesions and has been introduced into the therapy of central nervous
diseases. Lately it has been claimed that TMS would be useful not only in the
treatment of depression, but also in relieving symptoms of Parkinson’s disease.
In this study, we sought evidence of the effect of repetitive TMS on the symptoms
of Parkinson’s disease, the dose dependency between the applied elecromagnetic
field and the Parkinsonian symptoms, and the maintenance of the improvement.
Forty-nine patients with Parkinson’s disease were divided into four groups, each
given one stimulus, repeated 30 times, once or twice a day ( approximately
0.34Tesla (T), approximately 0.57T, approximately 0.80T). Patients were followed
for 3 months and assessed using two different parkinsonian scales: the graded
clinical rating scale and Unified Parkinson Disability Rating Scale (UPDRS), and
with a short-term memory test (Ziehen-Ranschburg word pair test). No effect was
seen in the group treated with approximately 0.34T30 stimuli once a day. In all
of the groups receiving TMS twice a day, the parkinsonian scores were
significantly decreased compared with that of baselines after 1 month of
treatment. The greatest improvement in the hypokinesia was detected in the group
treated with approximately 0.57T30 stimuli twice a day (baseline total UPDRS:
30.62 +/- 15.23; 1 month after treatment: 17.08 +/- 7.04, P < 0.01; 3 months
after treatment: 16.08 +/- 7.06, P < 0.01). A dose-dependent difference was
observed between the two groups after 3 months. The total UPDRS in Group II (
approximately 0.34T30 stimuli twice a day) significantly differed from Group III
( approximately 0.57T30 stimuli twice a day; 22.43 +/- 8.87, 16.08 +/- 7.06, P <
0.05). The long-lasting improvement effect with TMS would seem to suggest it as
an appropriate tool in the therapy of Parkinson’s disease.
PMID: 10467265 [PubMed – indexed for MEDLINE] 161. Compr Psychiatry. 1999 Sep-Oct;40(5):327-31.

A teaching guide for electroconvulsive therapy.

Kramer BA.

Cedars Sinai Medical Center, Los Angeles, CA 90048, USA.

Concern has been raised regarding the erratic and sometimes less than adequate
teaching of electroconvulsive therapy (ECT) to health professionals. The
development of standardized curricula will ultimately improve the quality of care
for patients receiving ECT and help to minimize the myths and misinformation
clinicians have regarding ECT. An outline for teaching ECT is presented that
covers the following areas: preconceptions, history, patient selection,
conditions of increased risk, medical and neurological side effects, memory
issues, technical aspects, electrode placement, clinical problems, management of
the post-ECT course, legal and ethical issues, mechanisms of action, and
educational issues. This outline can be expanded to encompass up to a 6-hour
course for psychiatric residents, or compressed to provide the basics to nursing,
medical, or pharmacy students.
PMID: 10509612 [PubMed – indexed for MEDLINE] 162. Neuropsychopharmacology. 1999 Aug;21(2):285-93.

Naloxone in the prevention of the adverse cognitive effects of ECT: a
within-subject, placebo controlled study.

Prudic J, Fitzsimons L, Nobler MS, Sackeim HA.

Department of Biological Psychiatry, New York State Psychiatric Institute, NY
10032, USA.

Electroconvulsive therapy (ECT) is a highly effective treatment for major
depression, but is also associated with characteristic cognitive side effects.
Several reports document that endogenous opioids and their receptors are
activated by electroconvulsive shock (ECS) and that naloxone in doses sufficient
to block endogenous opioid receptors may reverse ECS-induced retrograde amnesia.
This placebo-controlled, randomized, within-patient study was conducted to
examine the potential of naloxone, given in doses sufficient to block opioid
receptors (high dose), to ameliorate acute anterograde and retrograde memory
impairments following ECT. Compared to placebo and low dose naloxone, high dose
naloxone administered immediately before ECT resulted in significant reductions
in anterograde amnesia, and better performance on an attention task. Both low and
high dose naloxone improved verbal fluency. There were no beneficial effects of
high dose naloxone on retrograde amnesia, and an indication that high dose
naloxone may have worsened retrograde amnesia for shape stimuli. There were no
effects of high dose naloxone on seizure duration, vital signs, and subjective
side effects. The study is consistent with prior research in which change in
behavioral and physiological measures was produced principally by naloxone doses
sufficient to block endogenous opioid receptors and offers evidence of the
potential for ameliorating some adverse cognitive effects associated with ECT.
PMID: 10432476 [PubMed – indexed for MEDLINE] 163. Nervenarzt. 1999 Jul;70(7):662-7.

[Electroconvulsive therapy in the treatment of severe mania. Case report and a
state-of-art review] [Article in German]

Grunze H, Erfurth A, Schäfer M, Amann B, Meyendorf R.

Psychiatrische Klinik, Ludwig-Maximilians-Universität, München.

Despite newly developed pharmacological possibilities, treatment of acute mania
may still be a problem in single patients. Independent of the first choice of
medication, i.e. neuroleptics, lithium, carbamazepine or valproate, the average
response rate is only approximately 50-70%. Therefore, treating mania often
implies a number of monotherapeutic and polypharmaceutic attempts for several
months, until a sufficient mood stabilization has been reached. The aim of this
case report is to remind that electroconvulsive therapy (ECT) is still in use for
treating mania, which has been widely neglected in Germany despite its high
success rate, mainly reported from Anglo-Saxon countries. As demonstrated in this
report, ECT may be a useful tool for a fast antimanic response in patients which
may be either refractory to standard treatment or are medically severely ill, and
should, in our opinion, therefore be considered already at an earlier stage of
treatment in this group. However, persistence of improvement can usually only be
achieved with the overlapping start of drug treatment unless the option of
maintenance ECT is given.
PMID: 10434267 [PubMed – indexed for MEDLINE] 164. J Neurosci. 1999 Jun 15;19(12):5034-43.

Depression duration but not age predicts hippocampal volume loss in medically
healthy women with recurrent major depression.

Sheline YI, Sanghavi M, Mintun MA, Gado MH.

Department of Psychiatry, Washington University School of Medicine, St. Louis,
Missouri 63110, USA.

This study takes advantage of continuing advances in the precision of magnetic
resonance imaging (MRI) to quantify hippocampal volumes in a series of human
subjects with a history of depression compared with controls. We sought to test
the hypothesis that both age and duration of past depression would be inversely
and independently correlated with hippocampal volume. A sample of 24 women
ranging in age from 23 to 86 years with a history of recurrent major depression,
but no medical comorbidity, and 24 case-matched controls underwent MRI scanning.
Subjects with a history of depression (post-depressed) had smaller hippocampal
volumes bilaterally than controls. Post-depressives also had smaller amygdala
core nuclei volumes, and these volumes correlated with hippocampal volumes. In
addition, post-depressives scored lower in verbal memory, a neuropsychological
measure of hippocampal function, suggesting that the volume loss was related to
an aspect of cognitive functioning. In contrast, there was no difference in
overall brain size or general intellectual performance. Contrary to our initial
hypothesis, there was no significant correlation between hippocampal volume and
age in either post-depressive or control subjects, whereas there was a
significant correlation with total lifetime duration of depression. This suggests
that repeated stress during recurrent depressive episodes may result in
cumulative hippocampal injury as reflected in volume loss.
PMID: 10366636 [PubMed – indexed for MEDLINE] 165. Mem Cognit. 1999 May;27(3):501-11.

Relaxing decision criteria does not improve recognition memory in amnesic

Reber PJ, Squire LR.

University of California, San Diego, La Jolla, USA.

An important question about the organization of memory is whether information
available in non-declarative memory can contribute to performance on tasks of
declarative memory. Dorfman, Kihlstrom, Cork, and Misiaszek (1995) described a
circumstance in which the phenomenon of priming might benefit recognition memory
performance. They reported that patients receiving electroconvulsive therapy
improved their recognition performance when they were encouraged to relax their
criteria for endorsing test items as familiar. It was suggested that priming
improved recognition by making information available about the familiarity of
test items. In three experiments, we sought unsuccessfully to reproduce this
phenomenon in amnesic patients. In Experiment 3, we reproduced the methods and
procedure used by Dorfman et al. but still found no evidence for improved
recognition memory following the manipulation of decision criteria. Although
negative findings have their own limitations, our findings suggest that the
phenomenon reported by Dorfman et al. does not generalize well. Our results agree
with several recent findings that suggest that priming is independent of
recognition memory and does not contribute to recognition memory scores.
PMID: 10355239 [PubMed – indexed for MEDLINE] 166. Neurosci Biobehav Rev. 1999 May;23(5):635-48.

Adaptations and pathologies linked to dynamic stabilization of neural circuitry.

Kavanau JL.

University of California (UCLA), Department of Biology, Los Angeles 90095-1606,

Brain circuits for infrequently employed memories are reinforced largely during
sleep by self-induced, electrical slow-waves, a process referred to as “dynamic
stabilization” (DS). The essence of waking brain function in the absence of
volitional activity is sensory input processing, an enormous amount of which is
visual. These two functions: circuit reinforcement by DS and sensory information
processing come into conflict when both occur at a high level, a conflict that
may have been the selective pressure for sleep’s origin. As brain waves are
absent at the low temperatures of deep torpor, essential circuitry of hibernating
small mammals would lose its competence if the animals did not warm up
periodically to temperatures allowing sleep and circuit reinforcement. Blind,
cave-dwelling vertebrates require no sleep because their sensory processing does
not interfere with DS. Nor does such interference arise in continuously-swimming
fishes, whose need to process visual information is reduced greatly by life in
visually relatively featureless, pelagic habitats, and by schooling. Dreams are
believed to have their origin in DS of memory circuits. They are thought to have
illusory content when the circuits are partially degraded (incompetent), with
synaptic efficacies weakened through infrequent use. Partially degraded circuits
arise normally in the course of synaptic efficacy decay, or pathologically
through abnormal regimens of DS. Organic delirium may result from breakdown of
normal regimens of DS of circuitry during sleep, leaving many circuits
incompetent. Activation of incompetent circuits during wakefulness apparently
produces delirium and hallucinations. Some epileptic seizures may be induced by
abnormal regimens of DS of motor circuitry. Regimens of remedial DS during
seizures induced by electroconvulsive therapy (ECT) apparently produce temporary
remission of delirium by restoring functional or ‘dedicated’ synaptic efficacies
in incompetent circuitry. Sparing of sensory circuitry in fatal familial insomnia
seemingly owes to supernormal circuit use in the virtual absence of sleep. ECT
shocks and cardioverter defibrillation may have analogous remedial influences.
PMID: 10392656 [PubMed – indexed for MEDLINE] 167. J ECT. 1999 Mar;15(1):39-59.

Repetitive transcranial magnetic stimulation as a neuropsychiatric tool: present
status and future potential.

Post RM, Kimbrell TA, McCann UD, Dunn RT, Osuch EA, Speer AM, Weiss SR.

Biological Psychiatry Branch, National Institute of Mental Health, National
Institutes of Health, Bethesda, Maryland, USA.

Repetitive transcranial magnetic stimulation (rTMS) has emerged as a promising
therapeutic intervention in the treatment of affective disorders. The differences
in the type of electrical stimulation required for therapeutic efficacy by rTMS
and electroconvulsive therapy (ECT) are discussed. In contrast to ECT, rTMS would
not appear to require the generation of a major motor seizure to achieve
therapeutic efficacy. Accordingly, it carries the potentially important clinical
advantages of not requiring anesthesia and of avoiding side effects such as
transient memory loss. Preclinical studies on long-term potentiation (LTP) and
long-term depression (LTD) in hippocampal and amygdala slices, as well as
clinical data from neuroimaging studies, have provided encouraging clues for
potential frequency-dependent effects of rTMS. Preliminary evidence from position
emission tomography (PET) scans suggests that higher frequency (20 Hz)
stimulation may increase brain glucose metabolism in a transsynaptic fashion,
whereas lower frequency (1 Hz) stimulation may decrease it. Therefore, the
ability of rTMS to control the frequency as well as the location of stimulation,
in addition to its other advantages, has opened up new possibilities for clinical
explorations and treatments of neuropsychiatric conditions.
PMID: 10189618 [PubMed – indexed for MEDLINE] 168. J ECT. 1998 Dec;14(4):241-4.

Lithium and maintenance electroconvulsive therapy.

Gupta S, Austin R, Devanand DP.

Department of Psychiatry, Olean General Hospital, NY 14760, USA.

This clinical report describes the successful use of a combination of lithium
carbonate and maintenance electroconvulsive therapy (ECT) in the treatment of
severe bipolar depression. The patient was initially taken off the lithium and
given a course of ECT with remarkable improvement in symptoms. He subsequently
underwent maintenance ECT, during which lithium was restarted without any side
effects. Rating scales were used to assess memory, depression, and mental status.
This case suggests that the overlap of the two treatments may be especially
beneficial when the plan is to taper maintenance ECT while continuing
PMID: 9871844 [PubMed – indexed for MEDLINE] 169. J ECT. 1998 Dec;14(4):236-40.

Effects of TRH administration on orientation time and recall after ECT.

Zervas IM, Pehlivanidis AA, Papakostas YG, Markianos M, Papadimitriou GN,
Stefanis CN.

Department of Psychiatry, Athens University Medical School, Eginition Hospital,

We investigated the effect of thyrotropin-releasing hormone (TRH) on orientation
time and recall, in nine depressed female inpatients undergoing electroconvulsive
therapy (ECT). In a balanced order crossover design, an intravenous bolus of 0.4
mg TRH or placebo was administered 20 min before ECT in the first two sessions.
Orientation time and retrograde and anterograde components of the memory
dysfunction, immediately and 24 h later, were assessed. Administration of TRH did
not influence orientation time, word recall, or immediate short story recall
compared with placebo. We did find, however, an improvement in the number of
short story items recalled after 24 h when patients were given TRH compared with
placebo. This indicates that TRH may have a protective role against the specific
negative effect of ECT on delayed recall.
PMID: 9871843 [PubMed – indexed for MEDLINE] 170. J Neurol Neurosurg Psychiatry. 1998 Dec;65(6):890-8.

Forgetting rates in neuropsychiatric disorders.

Lewis P, Kopelman MD.

Division of Psychiatry and Psychology, United Medical and Dental Schools of Guy’s
and St Thomas’s Hospital, St Thomas’s Campus, London, UK.

OBJECTIVE: Previous studies have attributed accelerated forgetting rates on
recognition memory tasks to temporal lobe pathology, but findings in some patient
groups may have been attributable to metabolic disruption. Findings in
psychiatric disorders such as schizophrenia are conflicting. The purpose of the
present study was to compare forgetting rates in patients with confusional states
(post-electroconvulsive therapy (post-ECT), delirium), with those obtained in
schizophrenic patients (with putative temporal lobe pathology), non-ECT depressed
patients, and healthy controls. The findings could also be compared with previous
reports in patients with head injury, focal structural lesions, and Alzheimer’s
dementia. METHODS: Two studies employed a picture recognition task to examine
forgetting rates, the first between delays of 1 minute, 15 minutes, and 30
minutes, and the second between delays of 10 minutes, 2 hours, and 24 hours.
RESULTS: There were no significant differences in forgetting rates between 1
minute and 30 minutes, but the ECT group showed accelerated forgetting between 10
minutes and 2 hours compared with healthy controls, associated with a rapid
decline in “hit rate”. This was not attributable to differential changes in
either depression or severity of memory impairment. There were no differences in
forgetting rates across the other subject groups. CONCLUSION: Post-ECT
confusional state patients (similarly to “within post-traumatic amnesia” patients
with head injury) show accelerated forgetting on a recognition memory task and,
in this, they contrast with patients who have focal structural lesions or
widespread cortical atrophy. Accelerated forgetting may reflect the effect of
disrupted cerebral metabolism on either “consolidation” or memory “binding”
PMCID: PMC2170384
PMID: 9854966 [PubMed – indexed for MEDLINE] 171. Biol Psychiatry. 1998 Oct 1;44(7):610-6.

Effects of electroconvulsive therapy on plasma vasopressin and oxytocin.

Devanand DP, Lisanby S, Lo ES, Fitzsimons L, Cooper TB, Halbreich U, Sackeim HA.

Department of Biological Psychiatry, New York State Psychiatric Institute, New
York 10032, USA.

BACKGROUND: Animal studies suggest that vasopressin has cognitive-enhancing
properties and oxytocin may have amnestic effects. A clinical report suggests
that the acute increase in oxytocin-associated neurophysin predicts clinical
response to electroconvulsive therapy (ECT) in depressed patients. METHODS:
Medication-free patients with major depression were randomized to receive right
unilateral or bilateral ECT administered with electrical stimulus intensity at
either just above seizure threshold or at 150% above seizure threshold. The
associations between plasma vasopressin, oxytocin, ECT treatment parameters,
clinical outcome, and cognitive effects were assessed. RESULTS: The sample
comprised 55 patients. At the second ECT, patients receiving ECT at 150% above
initial seizure threshold had significantly greater increases in plasma
vasopressin than patients receiving low-dose ECT (ps < .01-.04), with no effects
of electrode placement. At the second and ninth ECT treatments, the vasopressin
or oxytocin surges were not associated with clinical improvement, seizure
duration, time to orientation, or memory test performance. There were inverse
trend-level associations between the acute surge in oxytocin levels at the ninth
ECT and clinical response, contradicting a report in the literature. CONCLUSIONS:
Overall, these findings do not support the hypothesis that diencephalic seizure
propagation is central to the mechanism of action of ECT.
PMID: 9787885 [PubMed – indexed for MEDLINE] 172. Nervenarzt. 1998 Jul;69(7):609-16.

[Effects of electroconvulsive therapy on cognitive functions in
therapy-refractory depression] [Article in German]

Hasse-Sander I, Müller H, Schurig W, Kasper S, Möller HJ.

Forschungsinstitut für Balneologie und Kurortwissenschaft, Bad Elster.

Within the context of an extensive study of electroconvulsive therapy at the
Psychiatric Clinic of the University of Bonn 15 patients suffering from
therapy-resistant Major depression (DSM III-R) were examined with a detailed
psychometric test battery, containing memory- and nonmemory tests. The test
battery had been applied short time before, during and after the treatment with
10 ECT applied unilateral over the nondominant hemisphere. Comparing the test
performances before and 1-2 days after the end of the series there were only few
remarkable changes: a significant decrease was diagnosed exclusively in 30 min
delayed recall of verbal items, while visual short-term memory and
visual-constructive performance showed a significant improvement (in spite of
unilateral stimulation on the right side). None of the other cognitive functions
inclusively speed of performances and reaction time was detracted short time
after the end of the ECT-treatment, instead all the measures improved albeit not
significantly. Between responders to treatment (50% improvement in HAMD) and
non-responders no significant differences neither before nor after the treatment
were detected. The non-responders had in nearly all of the tests some better (but
not significantly) results despite being older than the group of responders.
PMID: 9715479 [PubMed – indexed for MEDLINE] 173. J ECT. 1998 Jun;14(2):68-75.

A comparison of brief and ultrabrief pulse stimuli in unilateral ECT.

Pisvejc J, Hyrman V, Sikora J, Berankova A, Kobeda B, Auerova M, Sochorova V.

Kuffner Sanatorium, Horni Berkovice, Czech Republic.

A double-blind, randomized, comparative study of the therapeutic efficacy and
side effects of unilateral electroconvulsive therapy (ECT) given with two
different stimulus types was carried out in the Kuffner Sanatorium, Horni
Berkovice, Czech Republic. Brief or ultrabrief pulse stimuli were used in 48
hospitalized patients, ages 17-61 years, diagnosed with either schizophrenia (n =
42) or major depression (n = 6). All patients received eight unilateral
treatments each. Their clinical state and presence of cognitive impairment were
evaluated with a battery of tests and rating scales before ECT, after the last
ECT, and 1 month later. Patients were markedly improved after the course of ECT,
and the improvement was maintained 1 month later. There were no significant
differences in the extent of improvement between the groups treated with brief-
and ultrabrief-pulse stimuli. No deleterious effects on cognitive functions and
memory were detected. In fact, there was a trend toward improvement in memory and
other cognitive functions after ECT in both groups, with no significant
difference between them. The two stimulus waveforms studied (brief and ultrabrief
pulse) thus appear to be equally effective and free of deleterious effects on
memory and cognition. The response in schizophrenic patients was remarkable and
deserving of further study.
PMID: 9641801 [PubMed – indexed for MEDLINE] 174. Harv Rev Psychiatry. 1998 Mar-Apr;5(6):307-17.

A glutamatergic model of ECT-induced memory dysfunction.

Chamberlin E, Tsai GE.

Institute of Living, Hartford, Conn., USA.

Electroconvulsive therapy (ECT) is an efficacious treatment for a variety of
neuropsychiatric conditions including major depression, mania, catatonia,
Parkinson’s disease, and neuroleptic malignant syndrome. However, ECT-induced
memory dysfunction complicates the treatment and is a major concern for both
patients and providers. We briefly review ECT-induced memory dysfunction and
propose a glutamatergic model for it. (Articles examined were retrieved by a
Medline search on the terms electroconvulsion and glutamate, with language
limited to English.) Specifically, we hypothesize that ECT-induced memory
dysfunction results from neuronal insults due to excessive release of excitatory
amino acids and activation of their receptors, which produce cation and water
flux and reversible oxidative stress. This model offers multiple testable
hypotheses; exploring them may help to identify the risk factors for this
significant side effect of ECT treatment and may thus yield effective agents for
its prevention and treatment.
PMID: 9559349 [PubMed – indexed for MEDLINE] 175. Br J Psychiatry. 1998 Jan;172:44-8.

Cost and benefit in the choice of ECT schedule. Twice versus three times weekly

Shapira B, Tubi N, Drexler H, Lidsky D, Calev A, Lerer B.

Depression Treatment Unit, Herzog Hospital, Jerusalem, Israel.

BACKGROUND: We compared the antidepressant and cognitive effects of up to eight
sessions of bilateral, brief pulse electroconvulsive therapy (ECT) administered
twice (ECT x 2) or three times weekly (ECT x 3), to confirm that ECT x 3 acts
more rapidly although the two schedules are equivalent in antidepressant outcome,
and to establish whether ECT x 3 is indeed associated with more severe memory
impairment. METHOD: Patients with major depression, endogenous subtype were
randomly assigned to ECT x 3 or ECT x 2 plus one simulated ECT per week, both up
to a maximum of eight real ECT. Depression was evaluated by the Hamilton
Depression Scale the day after each treatment and cognitive function by a test
battery administered before and after the ECT series and at one month follow-up.
RESULTS: Assessed categorically or parametrically, there was no significant
difference in antidepressant outcome between the two schedules. Rate of response
was significantly more rapid with ECT x 3 but was associated with more severe
memory impairment. CONCLUSIONS: Twice weekly administration is an optimum
schedule for bilateral ECT unless clinical indications require the more rapid
antidepressant effect of three times weekly treatment.
PMID: 9534831 [PubMed – indexed for MEDLINE] 176. J Clin Psychiatry. 1998 Jan;59(1):8-13.

ECT in Texas: 19 months of mandatory reporting.

Reid WH, Keller S, Leatherman M, Mason M.

University of Texas Health Science Center, San Antonio, USA.

BACKGROUND: Texas law requires that all non-federal clinical facilities providing
electroconvulsive therapy (ECT) report every treatment to the state’s mental
health agency. The resulting data provide total population information about
treating physicians and hospitals; payment source; patient age, sex, ethnicity,
diagnosis, and admission/consent status; symptom severity and response; numbers
and types of treatments; and untoward events occurring within 14 days after
treatment. METHOD: We reviewed all reports of ECT between September 1993 and
April 1995 (2583 reports, approximately 15,240 treatments). RESULTS: About 6% (N
= 117) of Texas psychiatrists performed ECT during the period, at 50 hospitals.
One of 13 state-funded mental institutions performed ECT on-site; some
occasionally contracted with private hospitals. Almost all patients (88.1%) were
white. Some older age groups received proportionately more ECT than younger
groups, but no sharp increase was associated with eligibility for Medicare. Five
patients were less than 18 years of age; 70.3% were female. Virtually all
patients (99.0%) consented to the treatment themselves (rather than by guardian),
including committed-but-consenting patients (1.5%). Reports (5.8%) described
multiple-monitored treatment (MMECT, not depatterning). Group data indicated
generally good-to-excellent response, as measured by a five-point
symptom-severity scale. Eight patients died within 14 days of a treatment, 2
possibly of anesthesia complications and 3 others in accidents or by suicide.
Four were receiving maintenance treatments (generally about every other week). No
death appeared related to ECT stimulus or seizure. CONCLUSION: ECT in Texas is
performed by a small minority of psychiatrists and is unavailable to many
patients who need it. It is most accessible to white patients who receive care
outside the public sector. Our data support the common finding that ECT is
generally safe and effective.
PMID: 9491059 [PubMed – indexed for MEDLINE] 177. Seizure. 1997 Oct;6(5):351-9.

Seizures, memory and synaptic plasticity.

Reid IC, Stewart CA.

Department of Psychiatry, University of Dundee, Ninewells Hospital and Medical
School, UK.

Electrophysiological studies of the rodent hippocampus show that repeated seizure
activity has a profound, deleterious effect on an important form of synaptic
plasticity (long-term potentiation, LTP) which has been suggested to underlie
memory formation. It appears that seizure activity incrementally causes an
indiscriminate and widespread induction of long-term potentiation, consuming and
thereby reducing overall hippocampal plasticity available for information
processing. Consistent with this finding, severe deficits in a form of learning
known to be mediated by hippocampal function are observed in rat subjected to
repeated electroconvulsive seizures (ECS). The effect on synaptic function
gradually resolves over a period of around 40 days, paralleling the time course
of the transitory cognitive impairment seen following electrical seizure
induction (ECT) in humans being treated for severe affective disorder. The effect
is likely to be mediated by NMDA receptor activation during seizure activity, as
the phenomenon can be prevented by the administration of a non-competitive NMDA
receptor associated channel blocker (ketamine) immediately before seizure
induction. The mechanisms described may account for the inter-ictal cognitive
disturbance observed in patients suffering from poorly controlled epilepsy.
PMID: 9663798 [PubMed – indexed for MEDLINE] 178. Encephale. 1997 Jul-Aug;23(4):308-11.

[Use of electroconvulsive therapy in the adolescent] [Article in French]

Cohen D, Dubos PF, Basquin M.

Service de Psychopathologie de l’Enfant et de l’Adolescent, Clinique Georges
Heuyer, Hôpital de la Salpêtrière, Paris.

Despite the progress of pharmocotherapy, electroconvulsive therapy (ECT) is still
used in a majority of countries to treat severe intractable mental disorders of
the youth, yet few studies have been conducted to assess its use for individuals
under 20-year-old. Efficacy, indications, side effects, technical characteristics
and outcome are uncertain. A review of the 96 cases reported in the literature
shows that: 1) its average frequency in adolescent psychiatric practice is
similar throughout western nations and can be estimated around one ECT every year
per million people; 2) intractable mood disorders, both manic and depressive
episodes, are its main indications, since ECT treated more than 90% of the 66
cases reported; ECT can also offer an interesting alternative in some
schizoaffective and schizophrenic episodes, in particular catatonic ones; 3)
tolerance appears to be good, although secondary effects may occur. The most
serious ones are infrequent spontaneous seizures and more common memory loss.
Although no prospective studies are available on the evolution of cognitive side
effects, they seem to disappear within a few weeks.
PMID: 9417397 [PubMed – indexed for MEDLINE] 179. J Adv Nurs. 1997 Jul;26(1):120-5.

The problem of arriving at a phenomenological description of memory loss.

Moyle W, Clinton M.

Faculty of Health and Behavioural Sciences, Griffith University, Brisbane,

This paper discusses a methodological difficulty that arose when uncovering the
conscious experience of being nurtured as an in-patient with depression on a
psychiatric ward. It considers the problem of arriving at a phenomenological
description of memory loss in a patient who had undergone electroconvulsive
therapy (ECT). The paper begins by describing the prevalence of depression and
its significance for nurses working in in-patient settings. Examples of empirical
research into memory loss in depression are used to show what researchers must
set aside if they are to arrive at a phenomenological description of memory loss.
The choice of a phenomenological approach to the wider study from which the
methodological problem discussed here arose is then justified. The phenomena of
memory is introduced to show the methodological significance of attempting to
arrive at a phenomenological description of the statement made by one of the
participants, a woman being treated as an in-patient for major depression. A
possible description of the phenomena of memory loss based on the existential
phenomenology of Sartre is offered to call into question the ability of
researchers to bracket their assumptions. The significance for nurses of the
wider study from which our example is taken is then described. Finally it is
argued that despite the methodological difficulty described, a phenomenological
perspective based on the philosophy of Husserl can point nurses in the direction
of meeting the human needs of their patients.
PMID: 9231285 [PubMed – indexed for MEDLINE] 180. Convuls Ther. 1997 Jun;13(2):83-91.

Bridging the skull: electroconvulsive therapy (ECT) and repetitive transcranial
magnetic stimulation (rTMS) in psychiatry.

Kirkcaldie M, Pridmore S, Reid P.

Department of Psychological Medicine, Royal Hobart Hospital, Tasmania, Australia.

A brief account of repetitive transcranial magnetic stimulation (rTMS) with
reference to electroconvulsive therapy (ECT) is given, identifying similarities
and dissimilarities, and discussing their potential therapeutic roles. The
insulating properties of the skull prevent specific, noninvasive stimulation of
particular brain regions by direct electrical means. ECT allows electrical
stimulation of the cortex, but its concomitant seizures and distributed
electrical currents can have adverse effects on patients. By contrast, magnetic
fields pass almost without attenuation through the skull, and can induce
secondary electrical currents in localized areas of the brain. Subconvulsive rTMS
does not require seizure or general anesthetic, and does not affect memory.
Recent studies suggest that rTMS has therapeutic potential for mood disorders,
for which ECT is well established. rTMS is a new technology with the potential to
treat some mental disorders currently treated with ECT, with fewer side effects.
ECT will almost certainly remain the treatment of choice in some situations, but
ECT and rTMS may be alternatives for other patients. It is possible that rTMS
will become established in some areas where ECT is not used. Further research
will define these roles and evaluate the utility of rTMS.
PMID: 9253528 [PubMed – indexed for MEDLINE] 181. Encephale. 1997 Jun;23 Spec No 3:27-35.

[Are convulsions necessary for the antidepressive effect of electroconvulsive
therapy: outcome of repeated transcranial magnetic stimulation] [Article in French]

Post RM, Kimbrell TA, McCann U, Dunn RT, George MS, Weiss SR.

NIMH, Bethesda MD 20892-1272, USA.

Sismotherapy (ST) brings about numerous neurobiological changes, particularly
changes in neuromediators and their receptors, second messengers, neuropeptides
and neurotropic factors, a number of which are hypothesized to play a role in the
pathophysiology or therapeutics of affective disorders (M. Fink). What is not yet
known is which of these mechanisms is crucial for the psychotropic and
anticonvulsant effects of ST. However, it is clear that the effects of ST tend to
be relatively acute, and do not attack the deep-seated abnormalities that are the
underlying causes of recurrences of affective disorders. This is corroborated by
the fact that in animals, most of the effects of ECS on catecholamines and their
receptors (and on receptors for benzodiazepines or neuropeptides such as TRH)
tend to be relatively transient, and in most cases have been found to represent
compensatory adaptations to the induced motor convulsions. However, recent
preclinical data using attenuation, and clinical findings using reiterated
transcranial magnetic stimulation (rTMS), suggest that it may not be necessary to
provoke a clonic convulsion in order to achieve the beneficial psychotropic and
anticonvulsant effects of ST. In rodents receiving stimulation to the cerebellar
tonsil, seven daily subacute low-frequency sessions (stimulation at 1 Hz for 15
minutes) produced clear improvement in clonic convulsions and in post-discharge
thresholds, together with durable inhibition of convulsions when stimulation was
resumed (Weiss et al., 1995). Stimulation at 1 Hz for 15 minutes was more
effective than stimulation at 10 or 20 Hz in attenuating convulsions. Although
reiterated ECS also induced an anti-triggering effect, this dissipated rapidly
over five days (Post et al., 1984). It is of great interest that recent
publications have shown that rTMS at 10 or 20 Hz to the left frontal cortex,
administered to patients suffering from refractory depression (George et al.,
1995) or to patients (hospitalised or not) with milder degrees of depression
(Pasquale-Leon et al., 1996), had a moderate or marked antidepressant effect. In
these studies, rTMS showed few unwanted effects (other than mild pain in some
patients, due to contraction of the temporal muscles); it did not induce motor
convulsions, and did not, as such, appear to be associated with the memory loss
described in subjective accounts or in preliminary neuropsychological tests
(Little and Kimbrell et al., 1996). The optimal frequencies, durations and
positions for rTMS to maximise its antidepressant effect still remain to be
determined. However, the first controlled and open studies have tended to show
that (because of the capacity of rapid magnetic fluxes to produce sub-convulsant
electrical discharges that are relatively localised in the brain), rTMS may be
found to be a clinically useful antidepressant model. This would suggest the
possibility that some of the neurochemical changes induced by the clonic
convulsions of ECS could be directly induced by stimulation at the very edge of
the threshold (but still below it); this would open up the hope that one day
these endogenous neurochemical processes could be identified and exploited in an
optimal way for therapeutic purposes.
PMID: 9333558 [PubMed – indexed for MEDLINE] 182. Eur Neuropsychopharmacol. 1997 May;7(2):147-55.

Controlled trials of inositol in psychiatry.

Levine J.

Ministry of Health Mental Health Center, Faculty of Health Sciences, Ben Gurion
University of the Negev, Beersheva, Israel.

Inositol is a simple polyol precursor in a second messenger system important in
the brain. Cerebrospinal fluid inositol has been reported as decreased in
depression. A double-blind controlled trial of 12 g daily of inositol in 28
depressed patients for four weeks was performed. Significant overall benefit for
inositol compared to placebo was found at week 4 on the Hamilton Depression
Scale. No changes were noted in hematology, kidney or liver function. Since many
antidepressants are effective in panic disorder, twenty-one patients with panic
disorder with or without agoraphobia completed a double-blind,
placebo-controlled, four week, random-assignment crossover treatment trial of
inositol 12 g per day. Frequency and severity of panic attacks and severity of
agoraphobia declined significantly with inositol compared to placebo.
Side-effects were minimal. Since serotonin re-uptake inhibitors benefit obsessive
compulsive disorder (OCD) and inositol is reported to reverse desensitization of
serotonin receptors, thirteen patients with OCD completed a double-blind
controlled crossover trial of 18 g inositol or placebo for six weeks each.
Inositol significantly reduced scores of OCD symptoms compared with placebo. A
controlled double-blind crossover trial of 12 g daily of inositol for a month in
twelve anergic schizophrenic patients, did not show any beneficial effects. A
double-blind controlled crossover trial of 6 g of inositol daily vs. glucose for
one month each was carried out in eleven Alzheimer patients, with on clearly
significant therapeutic effects. Antidepressant drugs have been reported to
improve attention deficit disorder (ADDH) with hyperactivity symptomatology. We
studied oral inositol in children with ADDH in a double-blind, crossover,
placebo-controlled manner. Eleven children, mean age 8.9 +/- 3.6 years were
enrolled in an eight week trial of inositol or placebo at a dose of 200 mg/kg
body weight. Results show a trend for aggravation of the syndrome with
myo-inositol as compared to placebo. Recent studies suggest that serotonin
re-uptake inhibitors are helpful in at least some symptoms of autism. However a
controlled double-blind crossover trial of inositol 200 mg/kg per day showed no
benefit in nine children with autism. Cholinergic agonists have been reported to
ameliorate electroconvulsive therapy (ECT)-induced memory impairment. Inositol
metabolism is involved in the second messenger system for several muscarinic
cholinergic receptors. Inositol 6 g daily was given in a crossover-double-blind
manner for five days before the fifth or sixth ECT to a series of twelve
patients, without effect. These results suggest that inositol has therapeutic
effects in the spectrum of illness responsive to serotonin selective re-uptake
inhibitors, including depression, panic and OCD, and is not beneficial in
schizophrenia, Alzheimer’s ADDH, autism or ECT-induced cognitive impairment.
PMID: 9169302 [PubMed – indexed for MEDLINE] 183. Am J Psychiatry. 1997 Feb;154(2):156-64.

Modifiable neuronal connections: an overview for psychiatrists.

Jeffery KJ, Reid IC.

Department of Anatomy and Developmental Biology, University College London, U.K.

Synaptic plasticity is currently the target of much neurobiological research,
because it is thought to play an important role in brain function (particularly
memory formation). However, it has attracted little attention from psychiatrists
to date despite accumulating evidence that links it to various clinical
syndromes, including amnesia and possibly psychosis. The purpose of this article
is to present an overview of the two major arms of synaptic plasticity
research-theoretical (the field of neural network modeling) and neurobiological
(long-term potentiation). Artificial neural networks are a class of theoretical
model that has been developed with the aim of understanding how information
could, in principle, be represented by large numbers of interconnected and
relatively simple units. Over the past few decades, several theoretical accounts
of information-processing mechanisms have been developed, and these are briefly
reviewed. The principle common to representation formation in nearly all neural
networks is that of “associability”-the idea that streams of information are
combined by forming, strengthening, or pruning connections between them to form
new representations that can later be retrieved. Associability also lies at the
heart of psychological theories of information storage in the brain. Research
into associability has directed the attention of many experimenters toward the
possible biological correlates of such mechanisms. Of particular interest is the
recent discovery that some neurons appear to possess connections of modifiable
strength. The implications of this finding for psychiatry are discussed in
relation to representational disorders such as delusions and amnesia.
PMID: 9016262 [PubMed – indexed for MEDLINE] 184. New Dir Ment Health Serv. 1997 Winter;(76):85-96.

ECT in the elderly.

Greenberg RM.

ECT Service, Franciscan-Parkside Center, Saint Francis Hospital, Jersey City,

Depression is a common clinical problem in the elderly. Risk factors in this
population include genetic vulnerability, psychosocial losses, medical
comorbidity, cerebrovascular disease, and neurodegenerative disorders. Depression
in the elderly may have severe consequences, including high rates of suicide,
malnutrition or dehydration, high utilization of medical services, impaired
recovery from medical illnesses, and inappropriate placement in residential care
facilities. A significant number of older depressed patients may not respond to
anti-depressant medications, suffer intolerable medication side effects, or have
illnesses with symptoms or consequences so severe that it is not feasible to wait
the time required for one or more antidepressant trials to work. For many of
these patients ECT can be a dramatically effective treatment. With appropriate
evaluation and monitoring, ECT can be performed with relative safety even for
patients with serious concurrent medical illnesses. Serious adverse effects are
rare, and cognitive consequences of ECT are generally circumscribed and of
limited duration; there is no evidence of “brain damage” or permanent change in
cognitive ability from ECT. After a recovery period memory function is often
better than it was during the episode of depression. For patients who have been
refractory to or intolerant of medication, maintenance ECT can be an effective
strategy for preventing early relapse. Further research is needed, however, to
clarify the optimum use of MECT schedules and pharmacotherapy combinations to
most effectively and safely prevent relapse of depression in different elderly
populations and to help predict who will best respond to which treatment
PMID: 9520527 [PubMed – indexed for MEDLINE] 185. Psychopharmacol Bull. 1997;33(2):273-80.

Use of thyroid hormone to diminish the cognitive side effects of psychiatric

Tremont G, Stern RA.

Department of Psychiatry and Human Behavior, Brown University School of Medicine,
Providence, RI, USA.

Electroconvulsive therapy (ECT) and lithium are highly effective treatments for
mood disorders. Both treatments, however, are associated with cognitive side
effects which reduce patient compliance and treatment satisfaction. Both
therapies also have a significant effect on hypothalamic-pituitary-thyroid axis
(HPT) activity. Preliminary results from a double-blind, placebo-controlled study
of adjunctive thyroid hormone (T3) and ECT showed better memory function in
patients receiving T3 compared with placebo. This neuroprotective effect of T3
has been confirmed using electroconvulsive shock (ECS) in rats, and shown to be
independent of the number of electrical stimulations. Results of studies in
patients with bipolar disorder taking lithium have demonstrated that cognitive
deficits are significantly related to diminished thyroid status, but not lithium
levels. Preliminary evidence also shows that adjunctive thyroid hormone improves
cognitive functioning in patients taking lithium. These findings, if replicated
and confirmed, indicate a potential role for adjunctive thyroid hormone in
reducing the cognitive side effects of these important psychiatric treatments.
This, in turn, may lead to improved treatment compliance, diminished overall
morbidity, and reduced healthcare utilization.
PMID: 9230642 [PubMed – indexed for MEDLINE] 186. J Gerontol Nurs. 1996 Dec;22(12):14-20.

Electroconvulsive therapy and the elderly client.

Brandt B, Ugarriza DN.

University of Miami, School of Nursing, Coral Gables, Florida 33124-3850, USA.

Although ECT has been the subject of controversy for decades, ECT has brought
increased chances for recovery to many people suffering from severe depression.
Crossfield (1988) states the evidence is overwhelming that treatment of some
depressive clients with ECT is the best treatment available. Other researchers
have found that ECT is equal to, and sometimes superior to, other therapies for
major depressive disorders (Gomez & Gomez, 1993). Depression is a treatable
condition about which nurses have a responsibility to educate clients and their
families (Valente, 1991). If clients and their supportive families and friends
are to understand rather than undermine treatment, education about ECT is
essential (Valente, 1991). Well-meaning friends and family who are misinformed
could strongly discourage ECT, so it is important that their myths about ECT be
dispelled (Valente, 1991). Furthermore, if depression in an already at-risk
elderly population is not recognized and treated, great suffering will continue
to be endured and life-threatening situations may occur. Depression often is
manifested differently in older persons than in younger ones. Nurses can improve
the quality of care provided to these depressed elderly clients by allowing them
to express their fears and anger (Gomez & Gomez, 1993). Furthermore, the nurse’s
attitude should be hopeful, positive and consistent with them. This action can
help clients develop trust with the nurse and further their own quality care.
Estimates are that 70% to 90% of individuals who suffer from severe depression
and receive ECT do indeed recover (Valente, 1991). ECT should be undertaken only
after the outlined treatment protocols have been considered and with the
knowledge and understanding of the following statements issued by the United
States Department of Health and Human Services in the 1993 Agency for Health Care
Policy and Research (AHCPR). First, ECT has not been adequately tested in milder
forms of depression. Because of this gap in the research, the efficacy of ECT
across the spectrum of depressive symptomatology is unknown. Second, ECT is
costly when it entails hospitalization. This factor has great meaning in the
changing, increasingly cost-conscious, health care arena. Third, ECT has specific
and significant side effects, e.g., short-term retrograde and anterograde
amnesia. Not only are these side effects troublesome for inpatient recipients of
ECT, but the side effects can be quite dangerous for persons receiving treatment
on an outpatient basis. The potential for injury is grave for persons who have
memory deficit. Given the present cost-conscious, cost-cutting atmosphere, an
anticipated rise in the number of clients receiving ECT on an outpatient basis is
a distinct possibility. Fourth, the risks of general anesthesia are present. Age
is a well known risk factor for general anesthesia. Fifth, treatment with ECT
still carries substantial social stigma for clients. In spite of the increasing
acceptance of ECT as a treatment for depression in the elderly, many clients
prefer to keep their receipt of treatment secret fearing social repercussions of
open discussions with family and friends. Sixth, ECT can be contraindicated when
certain other medical conditions are present. Persons suffering from severe
cardiac or pulmonary disease are frequently disqualified for treatment due to the
risk of receiving anesthesia. Last, people usually require a prophylactic
treatment with antidepressant medication, even if a complete, acute phase
response to ECT is attained (pp. 26-27).
PMID: 9060342 [PubMed – indexed for MEDLINE] 187. J Affect Disord. 1996 Nov 4;41(1):9-15.

Bilateral ECT and autobiographical memory of subjective experiences related to
melancholia: a pilot study.

Peretti CS, Danion JM, Grangé D, Mobarek N.

INSERM Unité 405, Département de Psychiatrie, Hôpitaux Universitaires,Strasbourg,

The aim of this pilot study was to systematically assess the influence of
bilateral, sine wave ECT on autobiographical memory of past subjective
experiences related to melancholia. Twenty-one inpatients who met DSM-III-R
criteria for a Major Depressive Episode, Melancholic Type, were included in the
study. Twelve patients were treated by ECT (12 treatments), antidepressants and
benzodiazepines; the comparison group comprised 9 patients treated by
antidepressants and benzodiazepines. The Structured Interview Guide for the HDRS
(SIGH-D) was used at admission and after the ECT treatment to standardize data
collection about subjective experiences related to the depressive episode. Memory
of subjective experiences related to melancholia was assessed with free-recall,
cued-recall and recognition tasks. In addition, a free recall of events of the
day on which the patients came to the hospital for their treatment was
administered. These tasks were administered 1 week after the last treatment in
the ECT-treated group and 4 to 6 weeks after the beginning of the treatment in
the comparison group. Free-recall, cued-recall and recognition performances were
significantly lower in the ECT-treated group than in the comparison group. No
significant correlation was found between memory of events related to hospital
admission and memory of subjective experiences related to depression. In
conclusion, bilateral, sine wave ECT impairs autobiographical memory of
subjective experiences related to melancholia in subjects tested 1 week after
completion of a course of ECT.
PMID: 8938200 [PubMed – indexed for MEDLINE] 188. Epilepsia. 1996 Jul;37(7):618-24.

Competitive NMDA-receptor antagonists, LY 235959 and LY 233053, enhance the
protective efficacy of various antiepileptic drugs against maximal
electroshock-induced seizures in mice.

Borowicz KK, Gasior M, Kleinrok Z, Czuczwar SJ.

Department of Pharmacology and Toxicology, Lublin Medical University School,

PURPOSE: The objective of this study was to evaluate an interaction of two
competitive N-methyl-D-aspartate (NMDA)-receptor antagonists, LY 235959
l(-)-3R,4aS,6R,8aR-6-(phosphonomethyl)-decahydroiso-qu inoline-3-carboxylic acid;
< or = 0.5 mg/kg] or LY 233053 cis-(+/-)-4-[(2H-tetrazol-5-yl)
methyl]piperidine-2-carboxylic acid; < or = 5 mg/kg] with carbamazepine,
diphenylhydantoin, phenobarbital, or valproate magnesium against maximal
electroshock-induced convulsions in mice. METHODS: Electroconvulsions were
produced by means of an alternating current (ear-clip electrodes, 0.2-s stimulus
duration, tonic hindlimb extension taken as the end point) delivered by a
Hugo-Sachs stimulator (Type 221, reiburg, FRG). Adverse effects were evaluated in
the chimney test (motor performance) and passive-avoidance ask (long-term
memory). Plasma levels of antiepileptic rugs were measured by immunofluorescence.
RESULTS: Both LY 235959 and LY 233053 ( < or = 0.5 and 5 mg/kg, respectively) did
not influence the electroconvulsive threshold but potentiated the anticonvulsant
action of all antiepileptics studied. The combined treatment of LY 233053 (5
mg/kg) with carbamazepine, diphenylhydantoin, or phenobarbital (providing a 50%
protection against maximal electroshock) resulted in the impairment of long-term
memory. No adverse effects were observed with combinations of LY 235959 with
these antiepileptics. The combined treatment of valproate with either LY 235959
or LY 233053 was superior to valproate alone, as regards motor impairment, but
not the impairment of long-term memory. Neither NMDA-receptor antagonist elevated
the total plasma levels of antiepileptic drugs studied. CONCLUSIONS: It may be
concluded that NMDA-receptor blockade leads to the enhanced anticonvulsive action
of conventional antiepileptics against maximal electroshock-induced seizures. A
pharmacokinetic interaction does not seem probable.
PMID: 8681893 [PubMed – indexed for MEDLINE] 189. Epilepsia. 1996 Jul;37(7):610-7.

Influence of D-cycloserine on the anticonvulsant activity of phenytoin and
carbamazepine against electroconvulsions in mice.

Wla? P, Roli?ski Z, Czuczwar SJ.

Department of Pharmacology, Faculty of Veterinary Medicine, Agricultural
University, Lublin, Poland.

PURPOSE: D-Cycloserine (DCS) is a high-efficacy partial agonist at the
strychnine-insensitive glycine modulatory site within the N-methyl-D-aspartate
(NMDA)-receptor/ionophore complex. Previous studies demonstrated that DCS
exhibits anticonvulsant activity in a variety of experimental epilepsy models. In
this study, we determined the influence of DCS in subprotective doses on the
anticonvulsant action of phenytoin (PHT) and carbamazepine (CBZ) in mice.
METHODS: Two electroconvulsive tests were used, i.e., determination of seizure
threshold and maximal electroshock seizures. Antiepileptic drug-induced motor and
long-term memory deficits were quantified by using the chimney test and the
passive-avoidance test, respectively. In addition, plasma levels of PHT and CBZ
were measured by fluorescence polarization immunoassay to exclude any
pharmacokinetic interactions. RESULTS: DCS, when used alone in doses of 80 and
160 mg/kg, significantly increased the threshold for electroconvulsive seizures.
DCS in a wide range of doses (1.25-40 mg/kg) was combined with either PHT or CBZ
and tested in electroconvulsive tests. DCS, at doses of 2.5 and 10 mg/kg, was the
most effective in potentiating the threshold-increasing action of PHT; higher
doses of DCS (20 and 40 mg/kg) were required to achieve a similar effect of CBZ.
In maximal electroshock-induced seizures, DCS (10 mg/kg) augmented the protective
action of PHT, but was ineffective at a dose of 40 mg/kg with CBZ. DCS did not
potentiate the neurotoxicity produced by PHT and CBZ in the chimney test. Both
PHT and CBZ induced impairments of long-term memory; PHT-induced memory adverse
effects were counteracted by DCS (10 mg/kg). There was no such effect on
CBZ-induced memory impairment, and a worsening influence was observed. Any
pharmacokinetic interactions were excluded by measuring total and free plasma
levels of both antiepileptic drugs. CONCLUSION: Our results suggest that
combining DCS with PHT and CBZ may be beneficial in treating epileptic seizures.
PMID: 8681892 [PubMed – indexed for MEDLINE] 190. Biol Psychiatry. 1996 Mar 1;39(5):346-56.

Subjective memory complaints prior to and following electroconvulsive therapy.

Coleman EA, Sackeim HA, Prudic J, Devanand DP, McElhiney MC, Moody BJ.

Department of Biological Psychiatry, New York State Psychiatric Institute 10032,

Using the Squire Subjective Memory Questionnaire (SSMQ), depressed patients rated
their memory functioning prior to a course of brief pulse, electroconvulsive
therapy (ECT) within the 1 week following the course and 2 months later. Normal
controls made similar ratings at comparable intervals. Prior to ECT, patients
reported poorer memory functioning than controls. There was marked improvements
in the patients’ self-reports shortly following ECT, and at 2-month follow-up
SSMQ scores were generally comparable in patients and controls. At all time
points, the severity of depressive symptoms was strongly associated with
patients’ reports of memory dysfunction. SSMQ subscales (“depression” and “ECT”
items) were not differentially sensitive to effects of ECT or depression.
Relations between ECT treatment parameters and changes in patients’
self-evaluations only emerged after controlling for clinical state change.
Shortly following ECT, there were no relations between SSMQ scores and objective
measures of cognitive functioning. However, 2 months following ECT, there was a
suggestion that greater retrograde amnesia for autobiographical memories was
associated with self-rating of greater memory impairment.
PMID: 8704066 [PubMed – indexed for MEDLINE] 191. J Child Adolesc Psychopharmacol. 1996 Winter;6(4):259-71.

Electroconvulsive treatment in adolescents with pharmacotherapy-refractory

Ghaziuddin N, King CA, Naylor MW, Ghaziuddin M, Chaudhary N, Giordani B, Dequardo
JR, Tandon R, Greden J.

Department of Psychiatry, University of Michigan, Ann Arbor, USA.

The effectiveness and safety of ECT in pharmacotherapy-refractory depression was
examined in 11 hospitalized adolescents (ages 16.3 +/- 1.7 years, 10 females)
with a primary DSM-III-R diagnosis of mood disorder, which had failed to respond
to three or more adequate trials of antidepressant pharmacotherapy. After a
thorough diagnostic evaluation, patients received a course of ECT involving 11.2
+/- 2.0 (range 8-15) administrations. ECT was commenced with bilateral treatment
in 2 adolescents and nondominant right electrode placement in 9 patients; 5 of
the 9 patients were subsequently changed to bilateral treatment. All 11 patients
improved to a clinically significant degree. Significant improvements were noted
in scores on the Children Depression Rating Scale-Revised (CDSR-R) and the Global
Assessment of Functioning Scale (GAF) (p < 0.05). Euthymia, defined as CDRS-R
score < or = 40, was achieved by 64% (7/11) of patients. The Mini-Mental State
Examination showed no significant decline in cognitive functioning.
Neuropsychological testing completed in 5 subjects both before ECT and 1-5 days
after the last treatment, indicated a significant decline in attention,
concentration, and long-term memory search. Minor side effects, experienced
within the first 12 hours of treatment, were headache (80% of patients) and
nausea/vomiting (64%). The potentially serious complication of tardive seizure
(after full recovery of consciousness) occurred in 1 adolescent. Prolonged
seizures (> 2.5 minutes) were noted in 7 of the 11 patients (9.6% of the 135 ECT
administrations). Pending further research on ECT in youth, it is recommended
that ECT should only be administered to youth in hospital settings, that all
regularly administered psychotropic medications (including antidepressants) be
discontinued before ECT and restarted after the final administration of ECT, and
that physicians be aware that 12 treatments are usually sufficient, but that 15
treatments may occasionally be necessary for treating depressed adolescents. With
the understanding that scientific evaluation of ECT in youth is lacking, it
appears that ECT can be an effective and relatively safe treatment for depressed
adolescents who have failed to respond to antidepressant pharmacotherapy.
PMID: 9231319 [PubMed – indexed for MEDLINE] 192. Convuls Ther. 1995 Dec;11(4):232-40.

Subjective side effects during electroconvulsive therapy.

Devanand DP, Fitzsimons L, Prudic J, Sackeim HA.

New York State Psychiatric Institute, College of Physicians and Surgeons,
Columbia University, USA.

In 92 depressed patients who were randomized to unilateral or bilateral
electroconvulsive therapy (ECT) at either low dosage (just above seizure
threshold) or high dosage (2.5 times the seizure threshold), subjective side
effects were assessed with the Columbia ECT Subjective Side Effects Schedule. A
research nurse administered the instrument 4 h after each treatment during the
ECT course. In 41 patients, the instrument was also administered before the ECT
course. Headache, disorientation, and memory complaints were the most common
subjective side effects during the ECT course. Somatic side effects did not
change from early to late in the ECT course, and were not influenced by ECT
electrode placement or dosage. Most individual somatic side effects, including
nausea, tiredness, and muscle aches/pains did not change from pre-ECT to during
the ECT course, and may have been a function of the persistent somatic symptoms
of depression. Cognitive complaints increased from pre-ECT to during the ECT
course, but there was no overall change from pre-ECT to immediately after the ECT
course. Cognitive complaints were greater with bilateral compared with unilateral
ECT, with no significant effect of electrical dosage. During the ECT course,
subjective mood improved and psychomotor agitation decreased, particularly in
clinical responders. These findings suggest that most putative somatic side
effects are related to the depressive state rather than being induced by ECT. The
observed changes reinforce the need to evaluate both subjective and objective
side effects during ECT.
PMID: 8919573 [PubMed – indexed for MEDLINE] 193. Singapore Med J. 1995 Dec;36(6):647-50.

Chinese psychogeriatric patients in a general hospital.

Ko SM, Kua EH, Ang A.

Department of Psychological Medicine, National University of Singapore, National
University Hospital, Singapore.

A retrospective study of 100 consecutive elderly Chinese patients (29 males, 71
females) aged 65 years and above admitted to a general hospital psychiatric unit,
showed a predominance of depressive disorders (n = 36) and dementia (n = 26).
Depressed patients (mean age = 72.0; SD = 5.8) were significantly younger than
demented patients (mean age = 75.6; SD = 6.7) (p < 0.03). Patients with
depressive disorders presented with low mood, sleep disturbance, attempted
suicide as well as vague somatic symptoms in the absence of organic causes. Those
suffering from dementia presented with cognitive dysfunctions (especially memory
impairment), confusional state, deteriorated self care and sleep disturbance.
More than three quarters of the depressed patients were prescribed
antidepressants, and five had required electroconvulsive therapy. Almost nine out
of every ten patients had co-existing physical disorders, with one in two being
afflicted by two or more physical disorders; the average number of physical
disorders was 1.55 per patient. The commonest were cardiovascular disorders such
as hypertension (37%) and ischaemic heart diseases (12%). Endocrine disorders
like diabetes mellitus, constituted 21%. The mean duration of admission of all
patients was 16.3 days (SD = 12.6 days.)
PMID: 8781640 [PubMed – indexed for MEDLINE] 194. Br J Clin Psychol. 1995 Nov;34 ( Pt 4):505-15.

ECT and non-memory cognition: a review.

Calev A, Gaudino EA, Squires NK, Zervas IM, Fink M.

Department of Psychiatry and Behavioral Science, State University of New York at
Stony Brook 11794-8101, USA.

The literature on the effects of electroconvulsive therapy (ECT) on non-memory
cognitive functions is reviewed. It is concluded that with early methods of ECT
administration (sine wave, high dose), these effects are larger than those of
depression. They are less pronounced, and usually do not exceed the effects of
depression, when modern methods of ECT administration (brief pulse, moderate or
low dose) are used. Following ECT, these functions progressively improve. At one
week to seven months after ECT, performance is better than before ECT, probably
because of the alleviation of both the effects of depression and of ECT. The time
course to full recovery of the non-memory effects resembles that of the recovery
of amnesic effects, although the latter are more pronounced. With bilateral ECT,
as with right unilateral ECT, there is evidence that right hemisphere effects are
more pronounced. The results of this review argue that clinicians should take the
non-memory cognitive effects of ECT into account, and patients should be informed
of their existence before they sign consent for ECT.
PMID: 8563658 [PubMed – indexed for MEDLINE] 195. J Psychiatr Res. 1995 Nov-Dec;29(6):487-9.

Lack of effect of 6 g inositol treatment of post-ECT cognitive function in

Levine J, Pomerantz T, Stier S, Belmaker RH.

Ministry of Health Mental Health Center, Faculty of Health Sciences, Ben Gurion
University of the Negev Beersheva Israel.

Cholinergic agonists have been reported to ameliorate ECT-induced memory
impairment. Inositol metabolism is involved in the second messenger system for
several muscarinic cholinergic receptors. Inositol 6 g daily was given in a
cross-over double-blind manner for 5 days before the 5th or 6th ECT in a series
of patients. No effect was found on post-ECT cognitive impairment.
PMID: 8642546 [PubMed – indexed for MEDLINE] 196. Convuls Ther. 1995 Sep;11(3):192-201.

Cognitive effects of electroconvulsive therapy: a clinical review for nurses.

Durr AL, Golden RN.

Department of Psychiatry, University of North Carolina School of Medicine, Chapel
Hill 27599, USA.

Cognitive deficits are undesirable effects of electroconvulsive therapy (ECT).
This article reviews the cognitive impairments associated with ECT, with an
emphasis on linguistic information processing and memory dysfunction. Factors
that may have an impact on the cognitive effects of ECT are discussed, along with
recommendations for clinical interventions to aid in the treatment of these
PMID: 8528663 [PubMed – indexed for MEDLINE] 197. Am J Psychiatry. 1995 Jul;152(7):995-1001.

Predictors of retrograde amnesia following ECT.

Sobin C, Sackeim HA, Prudic J, Devanand DP, Moody BJ, McElhiney MC.

Department of Biological Psychiatry, New York State Psychiatric Institute, NY
10032, USA.

OBJECTIVE: Substantial progress has been made in identifying how the treatment
parameters used in ECT impact on cognitive side effects. However, there is
limited information regarding individual differences in vulnerability to these
side effects. The authors examined patients’ pretreatment global cognitive status
and postictal orientation recovery time as potential predictors of the magnitude
of retrograde amnesia for autobiographical memories after ECT. METHOD:
Seventy-one inpatients with major depressive disorder were randomly assigned to
four ECT conditions that varied in electrode placement (right unilateral versus
bilateral) and stimulus dosage (low versus high intensity). Orientation recovery
time was assessed at virtually every session during the course of ECT. Global
cognitive status was assessed with the modified Mini-Mental State examination
before treatment, during the week after termination of treatment, and 2 months
after treatment ended. Retrograde amnesia was assessed at these same time points
with the Autobiographical Memory Interview. RESULTS: Pre-ECT global cognitive
status and the duration of postictal disorientation were strong predictors of the
magnitude of retrograde amnesia in the week after the course of ECT and at
2-month follow-up. In general, these relationships were maintained regardless of
technical parameters in the administration of the ECT. CONCLUSIONS: Patients who
manifest global cognitive impairment before treatment and patients who experience
prolonged disorientation in the acute postictal period may be the most vulnerable
to persistent retrograde amnesia for autobiographical information.
PMID: 7793470 [PubMed – indexed for MEDLINE] 198. Convuls Ther. 1995 Mar;11(1):32-7.

Patient knowledge about electroconvulsive therapy: effect of an informational

Westreich L, Levine S, Ginsburg P, Wilets I.

Beth Israel Medical Center, New York, New York, USA.

We wished to ascertain whether the addition of an informational video to the
informed consent procedure for electroconvulsive therapy (ECT) results in
improved patient knowledge about ECT. Eighteen ECT patients were randomized to
consent using the usual written document or using the written document and an
informational video. The two groups were similar when compared on demographic
variables and scores on the Brief Psychiatric Rating Scale (BPRS) and Mini-Mental
State Examination (MMSE). Each subject, just after signing the informed consent
document, was administered an 8-question ECT knowledge questionnaire. The
addition of an informational video to the consent process for ECT did not result
in improved knowledge about ECT. Poor knowledge about ECT might be accounted for
by unsuccessful communication from the doctors or cognitive impairment and apathy
on the part of the patients. One benefit of the video was increased interest from
family members in ECT and the consent process.
PMID: 7796066 [PubMed – indexed for MEDLINE] 199. J Neuropsychiatry Clin Neurosci. 1995 Winter;7(1):31-4.

Improvement in depression-related cognitive dysfunction following ECT.

Stoudemire A, Hill CD, Morris R, Dalton ST.

Department of Psychiatry, School of Medicine, Emory University, Atlanta, GA
30322, USA.

Long-term cognitive changes were observed in 8 depressed patients whose
pretreatment cognitive impairment (depressive dementia or pseudodementia)
resolved after treatment with ECT. Improved performance on the Mattis Dementia
Rating Scale was maintained throughout a 4-year follow-up period. Improvements on
Memory and Initiation and Perseveration subscales were most consistent over time.
These aspects of cognitive functioning may be the most susceptible to the effects
of depression, and this may be a factor to consider in clinically evaluating
older patients with both depression and cognitive impairment. The findings
indicate that elderly patients with cognitive dysfunction secondary to depression
may experience improvement in cognitive functioning that is stable over time with
remission of the affective disorder.
PMID: 7711488 [PubMed – indexed for MEDLINE] 200. Encephale. 1994 Nov-Dec;20(6):781-3.

[Randomized study of the therapeutic effect of electroconvulsive therapy, uni- or
bilateral, on certain cognitive functions in depression, with
electroencephalography monitoring. Preliminary results] [Article in French]

Maître L, Hartmann F, Poirier MF, Amado-Boccara I, Brochier P, Olié JP, Lôo H.

Service Hospitalo-Universitaire de Santé Mentale et de Thérapeutique, CHS
Sainte-Anne, Paris.

Cognitive functions are known to be impaired by ECT. The aim of this study is to
differentiate the effects of electroconvulsive therapy on some cognitive
functions according to the mode of application of the electrodes. The brief-pulse
Thymatron DG apparatus allows to control four electrical parameters and to assess
electroencephalographic data. The preliminary sample comprises nine patients
suffering of major depressive disorder; they are randomly assigned to the mode of
application of the electrodes, bilateral or unilateral to the non dominant
hemisphere. Clinical evolution is surveyed by the Montgomery and Asbert
Depression Rating Scale. Non mnesic functions are assessed: arousal by CFF
(Critical Fusion Frequency), and attentional, motor and decisional abilities by
CRT (Choice Reaction Test). Different mnesic function are studied by selective
reminding test, cued recall test, block tapping test and picture fragmentation
test. After treatment by ECT, verbal mnesic functions assessed by selective
reminding test are impaired with the bilateral application. Whereas they are not
modified with the unilateral application. The variance of CFF regains a
physiological value in the bilateral group, but remains altered in the
PMID: 7875113 [PubMed – indexed for MEDLINE]