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.