Concern about cognitive effects is the main reason ECT is not more widely prescribed for severe depression. ECT is mistakenly considered a “last resort” treatment, one that appears far down the list in treatment algorithms, if it is considered at all.1
This delay or failure to appropriately prescribe ECT results in seriously ill patients remaining depressed for prolonged periods; sometimes it results in suicides that could have been prevented or death from medical causes.2
The concern about cognitive effects is exaggerated; most ECT patients experience minor cognitive impairment, much of which is temporary. The restricted use of ECT because of overstated fears of memory loss is a significant public health problem. Part of this problem stems from the fact that the cognitive effects of ECT are considered a safety issue. I suggest that it is more appropriate to consider the cognitive impact of ECT a tolerability issue.
In medicine, safety almost always refers to risk (or lack thereof) of physical injury or death. When we think of the safety of a medical or surgical procedure, we consider first the mortality rate then the rate of complications, such as infection, disfigurement, or ongoing pain. All surgical procedures result in temporary postoperative pain, yet we never consider this part of the safety profile of the procedure. Likewise, with chemotherapy, we think of safety as the risk of blood dyscrasias and immunosuppression; temporary hair loss and “chemo brain,” are unpleasant adverse effects, but not typically considered “safety” issues. This may have to do with the general acceptance of the idea that cancer is a life-threatening illness and the risk to benefit ratio clearly favors accepting bothersome, but nonserious, adverse effects in return for extended life.
Semkovska and McLoughlin3 performed a systematic review and meta-analysis of 84 studies (N = 2981) that used standardized tests to assess cognition in ECT patients. They concluded:
. . . cognitive abnormalities associated with ECT are mainly limited to the first 3 days posttreatment. Pretreatment functioning levels are subsequently recovered. After 15 days, processing speed, working memory, anterograde memory, and some aspects of executive function improve beyond baseline levels.
While some patients experience more substantial memory impairments, this is not typical. The most commonly reported memory effect, retrograde amnesia, represents the loss of certain past memories, a static (unless the memories return, in which case it is improving) content problem, not an ongoing problem of memory functioning.
1. Beale MD, Kellner CH. ECT in treatment algorithms: no need to save the best for last. J ECT. 2000;16:1-2.
2. Belaizi M, Yahia A, Mehssani J, et al. Acute catatonia: questions, diagnosis and prognostics, and the place of atypical antipsychotics [in French]. Encephale. 2012 Oct 11; [Epub ahead of print].
3. Semkovska M, McLoughlin DM. Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. Biol Psychiatry. 2010;68:568-577.
4. Guze SB, Robins E. Suicide and primary affective disorders. Br J Psychiatry. 1970;117:437-438.
5. American Psychiatric Association. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. 2nd ed. Washington, DC: American Psychiatric Association; 2001.
6. Watts BV, Groft A, Bagian JP, Mills PD. An examination of mortality and other adverse events related to electroconvulsive therapy using a national adverse event report system. J ECT. 2011;27:105-108.
7. Janicak PG, Davis JM, Gibbons RD, et al. Efficacy of ECT: a meta-analysis. Am J Psychiatry. 1985;142:>297-302.
8. Prudic J, Haskett RF, Mulsant B, et al. Resistance to antidepressant medications and short-term clinical response to ECT. Am J Psychiatry. 1996;153:985-992.
9. Kellner CH, Knapp RG, Petrides G, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry. 2006;63:1337-1344.
10. Husain MM, Rush AJ, Fink M, et al. Speed of response and remission in major depressive disorder with acute electroconvulsive therapy (ECT): a Consortium for Research in ECT (CORE) report. J Clin Psychiatry. 2004;65:485-491.
11. Sienaert P, Vansteelandt K, Demyttenaere K, Peuskens J. Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: cognitive side-effects. J Affect Disord. 2010;122:60-67yes.