Health-related quality of life can provide a simultaneous and net assessment of the therapeutic and adverse affects of psychiatric treatments for depression. While the cognitive side effects of ECT might be thought of as a limiting factor in HRQOL gains, they have not been systematically studied until recently. Find out what quantitative assessment of HRQOL following ECT for major depressive disorder shows.
Health-related quality of life (HRQOL) can be defined as a broad array of outcomes that go beyond syndrome-specific symptoms or mortality and can include satisfaction and competence in primary life role (e.g., student, homemaker or breadwinner), satisfaction and competence in relationships, freedom from pain and mental anguish, energy, and other broad and subjective psychosocial constructs affected by one's health. Health-related quality of life is part of the larger concept of QOL, which includes some aspects of living that, while important, do not necessarily directly reflect health per se, such as spiritual satisfaction, lack of crowding and availability of a stimulating environment. Of necessity, HRQOL must be defined with reference to the patient's values (Asadi-Lari et al., 2004) and cannot always be subjected to external validation, in contrast to more objective measures of function such as activities of daily living, which can be validated by direct observation (McCall et al., 2002).
Why is HRQOL important to psychiatry and, more specifically, to the practice of electroconvulsive therapy? The Institute of Medicine quality improvement blueprint calls for care that is both evidence-based and customized based upon patient needs and values (Committee on Quality Health Care in America, 2001). In a world with limited resources for the treatment of disease, HRQOL is a useful means of contrasting the overall impact of different diseases on patients' lives. For example, HRQOL creates a common language that allows a comparison of the impact of problems as disparate as orthopedic problems and cancers. Similarly, treatments of different diseases can be contrasted for their relative value in improving HRQOL. Going further, the relative cost of a unit of improvement in HRQOL for different treatments of different diseases can be compared, facilitating optimal allocation of scarce health resources.
Health-related quality of life can also assist in determining the relative health benefits of treatments that have both high efficacy and significant side effects. In the example of cancer, HRQOL can simultaneously take into account the therapeutic action of chemotherapy and its adverse effects, giving some sense of the overall net impact of chemotherapy on health.
HRQOL and Depressive Illness
In the same vein, HRQOL can provide a simultaneous and net assessment of the therapeutic and adverse effects of psychiatric treatments. Major depressive disorder (MDD) has been identified as the candidate for the second leading cause of poor HRQOL in the world by the year 2020 (Murray and Lopez, 1996). This phenomenon is predicted by both the high world prevalence of MDD as well as the greater negative impact of MDD on HRQOL as compared with the impact of other common conditions, such as arthritis, diabetes or coronary disease (Wells et al., 1989). Within samples of patients with depression, severity of depression is related to the extent of HRQOL deficits, and the type of deficit depends in part upon the age of the patient with depression (McCall et al., 1999a).
Therefore, antidepressant treatments, including ECT, would be expected to have the potential for producing large improvements in HRQOL that would be of relevance to public health. Indeed, successful treatment of depression is associated with improvements in HRQOL (McCall et al., 2001). Conversely, partial antidepressant response and failure to achieve a complete remission, leaving the patient with ongoing residual symptoms, is associated with worse HRQOL (Zimmerman et al., 2004).
While antidepressant medications have side effects that could potentially offset some of the HRQOL gains that come with successful medication treatment of depression, the issue of side effects offsetting antidepressant effects is of even greater interest with ECT. The cognitive side effects of ECT, specifically amnesia, might be predicted to be a limiting factor on HRQOL gains resulting from ECT's antidepressant effect. It is well established that depressed mood and cognitive deficits have additive negative effects on functional capacity. For example, secondary depression limits functional capacity in people with primary dementia (Espiritu et al., 2001; Pearson et al., 1989) and, conversely, secondary cognitive deficits are associated with limitations of functional capacity in people with primary MDD (McCall and Dunn, 2003). For these reasons, it is reasonable to take a hard look at ECT and the potential for simultaneous and offsetting effects of change in mood and memory on HRQOL.
Concerns About ECT and HRQOL
A few nonprofessional organizations have a taken a vocal and consistently negative attitude toward ECT. The directors of these organizations do not deny the acute antidepressant efficacy of ECT; instead, they argue that the cognitive side effects of ECT are so severe and persistent that patients' lives can be nearly ruined (Andre, 2005a). These organizations may not specifically use the terms HRQOL and functional capacity, but the charges they lay against ECT are nevertheless within these domains. These charges are usually supported by a biased selection of individuals who were unhappy with their own outcome as ECT patients. Despite a lack of systematic, unbiased information on the effects of ECT on HRQOL, these organizations occasionally make incursions into mainstream psychiatric journals (Andre, 2005b; McCall, 2005).
Very recently, governmental health regulatory agencies have expressed concern over a perceived lack of sufficient data on the effects of ECT on HRQOL. This concern, among others, led to the recommendation to restrict ECT, including a recommendation against ECT in non-life-threatening circumstances unless the patient fails multiple trials of antidepressant medications during each new episode of MDD (National Institute for Clinical Excellence, 2003).
Quantitative assessment of HRQOL using established assessment tools is a relatively new development in the area of ECT. Thienhaus et al. (1990) were among the first to apply established quantitative assessments of HRQOL in ECT, looking at change in the Global Assessment of Functioning (GAF) scale. In their case series of six older patients (mean age=71±5) who received a course of ECT followed by continuation ECT, they found that GAF scores increased from 53±11 to 68±11. Statistical testing was not reported for the change in GAF scores.
We later found a similar magnitude of effect following an acute course of ECT (Dew et al., 2005). Change of this size would be best viewed as indicative of a moderate positive effect of ECT on function, but leaving the patients with residual global impairment. A limitation of the GAF is that it attempts to parse the limitations in the individual's functional capacity to separate bins pertaining to mental-health-related disability versus disability due to other causes. Making the distinction between mental-health-related disability and medical disability becomes an impossible task in patients with multiple concurrent psychiatric and medical problems, as may be seen in the older patient treated with ECT.
In a later paper, the change in social functioning after a course of ECT was followed in 40 patients using the Social Functioning Schedule (SFS) (Casey et al., 1996). The SFS scale includes measures of employment, household chores, finance, self care, relationships and recreation. The researchers tracked SFS scores prior to onset of ECT and every six weeks up to six months. Again, statistical testing on the difference between pre- and post-ECT SFS scores was not presented, but the numerical change in scores is impressive, showing an approximately 80% improvement in SFS scores from baseline to six months post-ECT.
We subsequently began a series of studies examining the effect of ECT on HRQOL and function. In the first study, we contrasted 31 depressed inpatients treated with ECT with 59 depressed inpatients treated with medications (McCall et al., 1999b). Assignment to medications versus ECT was nonrandom and was at the discretion of the attending psychiatrist. Health-related quality of life was assessed with the daily-living/role functioning (DLRF) and relationship to self/others (RSO) subscales of the Behavior and Symptom Identification Scale (BASIS-32), while functional capacity was assessed with an instrumental activities of daily living (IADL) scale. The ECT-treated patients were older than the medication-treated patients, but the two groups were not different in overall depression severity. Instead, the older ECT-treated patients reported a lesser scope of activities on the IADL scale and more problems on the DLRF scale. These patients were then followed for 12 months, revealing that the degree of improvement in depression scores, DLRF improvement and IADL improvement were significantly greater in the ECT group than the medication group after one year (McCall et al., 2001). This finding must be tempered by the nonrandom assignment to medications versus ECT.
We then studied a new series of depressed, ECT-treated patients with the BASIS-32 and IADL scales before ECT and at two and four weeks after ECT, but this time including comprehensive measurement of memory in addition to standard assessment of mood (McCall et al., 2004). Significant improvement in the IADL scale and the DLRF subscale of the BASIS-32 were seen at two and four weeks, with greater than or equal to 80% of patients reporting improvement on each HRQOL and function measure.
Most recently, we have used the Medical Outcomes Study Short Form-36 (SF-36) as a generic measure of HRQOL (unpublished data). In this study, 283 patients were tested before ECT, immediately after and again at six months. Eighty-seven percent of patients had improvement in the SF-36 score immediately after ECT, and 78% still showed positive change at six months. Importantly, patients who did not respond to ECT or who subsequently relapsed overall still showed improved SF-36 scores compared to baseline. Similar effects of ECT on the SF-36 were reported by Fisher et al. (2004).
There is accumulating evidence that ECT is associated with improvements in HRQOL and function and that this improvement is seen soon after ECT and is maintained for up to one year. The degree of change in HRQOL and function in patients with depression is greater with ECT than with medication. These effects are seen with a variety of different assessment tools (Table). Improvement in mood explains most of the improvement in HRQOL and function, and the majority of ECT-treated patients experience an improvement in these measures over the first few months.
Overall, these findings support the idea that ECT is a helpful experience for most patients and are convergent with other data sources showing that ECT does not cause structural change in the brain or persistent effects on whole brain metabolism. In general, ECT is followed by a net improvement in health for most patients with depression. However, our findings do not discount the minority of patients who have worse HRQOL after ECT or that a small number of individuals may find the side effects of ECT disabling.
Dr. McCall is chairperson and professor in the department of psychiatry and behavioral medicine at Wake Forest University Health Sciences.
Dr. Rosenquist is professor in the department of psychiatry and behavioral medicine at Wake Forest University Health Sciences.
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