Department of Psychiatry and Behavioral Medicine, Wake Forest University Health Sciences, Winston-Salem, North Carolina, USA
Correspondence: W. Vaughn McCall, Department of Psychiatry and Behavioral Medicine, Wake Forest University Health Sciences, Medical Center Boulevard, Winston-Salem, North Carolina 27157-1071, USA. Tel: 336 716 2911; fax: 336 716 3508; e-mail: vmccall{at}wfubmc.edu
Declaration of interest None. Funding detailed in Acknowledgement.
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ABSTRACT |
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Aims To examine the effects of ECT on function and quality of life, particularly as they relate to changes in mood and cognition in the month following this therapy.
Method We measured changes in quality of life, function, mood and cognition in a prospective sample of 77 depressed patients given ECT.
Results All quality of life and function outcomes were improved at the 2-week and 4-week marks after ECT. Improvement in quality of life was related to mood, whereas improvement in instrumental activities of daily living function was related to improvement in global cognition.
Conclusions Electroconvulsive therapyis associated with early improvement in function and quality of life. A restrictive attitude towards this therapy is not warranted on the basis of its effects on quality of life and function.
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INTRODUCTION |
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Indeed, the literature on mood and cognition has generally shown that poorer cognitive status is associated with worse quality of life in patients with depression. These relationships are true whether the sample of interest is patients with depression secondary to dementia (Pearson et al, 1989) or patients with primary depression and secondary cognitive dysfunction (McCall & Dunn, 2003). These observations suggest that the cognitive side-effects of ECT should limit any beneficial antidepressant effect on quality of life. However, we and others have previously shown that ECT results in a net improvement in function and quality of life for a period of at least 1 year after treatment (McCall et al, 2001; Casey et al, 1996). We have therefore examined the simultaneous, respective contributions of antidepressant efficacy and cognitive side-effects to the changes in function and quality of life in patients given ECT. We began with the hypothesis that antidepressant efficacy would be associated with improvement in function and quality of life, whereas cognitive side-effects would be associated with a dampening of function and quality of life in patients treated with ECT.
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METHOD |
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Procedure
Right unilateral electrode placement followed the dElia position,
whereas bilateral placement was in the frontotemporal position
(DElia & Raotma,
1975). Electrode placement was randomly assigned. A MECTA SRI
device (MECTA Corp., Tualatin, Oregon, USA) delivered the constant current,
bidirectional brief pulse. Seizure threshold was estimated in all patients at
the first therapy session, with an approximately 50% increment change at each
subsequent session. Patients with right unilateral placement received a
stimulus 8 times their initial seizure threshold at the second and subsequent
treatment sessions, while patients in the bilateral placement group received a
stimulus 1.5 times their seizure threshold at the second and subsequent
treatment sessions. Additional details of ECT technique can be found elsewhere
(McCall et al,
2002a). The total number of treatments was determined by
the ward psychiatrist, who was masked to the patients randomisation
status.
Depression severity and response criteria
Patients provided a self-report of depression severity with the Beck
Depression Inventory (BDI; Beck et
al, 1988), and a trained rater masked to patient status
measured depression severity with the 21-item HRSD following a semi-structured
interview. The HRSD was completed 13 days prior to the first ECT
session, 24 h after each mid-course session, 12 days after the last
session, and 2 weeks and 4 weeks after the last session. The BDI was completed
before and immediately after the course of therapy, and at 2 weeks and 4 weeks
after the last session. Antidepressant response was defined as a decrease of
at least 60% in HRSD scores and a final score of 12 or less after completion
of the therapy. Relapse among the responders was defined as a 50% increase in
HRSD scores from the end of therapy and an HRSD score of 14 or more at both
the 2-week and the 4-week intervals.
Cognitive assessment
Cognition was assessed 13 days prior to ECT, 12 days after
the course of ECT and at 2 and 4 weeks after ECT by a masked rater. Global
cognition was evaluated with the MMSE. Retrograde autobiographical memory was
measured with the Personal Memory Questionnaire
(McElhiney et al,
1995). Anterograde amnesia for verbal memory function was assessed
with the Rey Auditory Verbal Learning Test
(Ryan et al, 1986)
with a 20 min delay (RAVLTDR). Anterograde amnesia for figural memory
function was tested with the Rey Complex Figure Test (Recall Phase) with a 20
min delay (RCFTDR; Spreen &
Strauss, 1991).
Function and quality of life
Function was measured with an instrumental activities of daily living
(IADL) scale and an activities of daily living scale, the Personal
Self-Maintenance Scale (PSMS; Lawton &
Brody, 1969). The IADL scale has been shown to be sensitive to
change in this sample and to demonstrate good reliability between patients and
their care-givers, with a correlation of 0.95 for the change scores
(McCall et al,
2002b). Quality of life was assessed with the Daily
Living and Role Functioning (DLRF) sub-scale and the Relationship to Self and
Others (RSO) sub-scale of the Basis-32 instrument
(Eisen et al,
1994).
Statistics
Means are reported with standard deviations. The means of continuous
variables were compared with t tests or adjusted analyses of
variance. Frequency distributions were compared with the 2
statistic. Models of the change in function and quality of life were created
for the 2-week and 4-week post-ECT time points, compared with the pre-ECT
baseline. A total of eight linear regression models were created (DLRF, RSO,
IADL and PSMS scores at both 2 weeks and 4 weeks). All measurements within the
models were expressed as the percentage change from baseline, with the
exception of age and gender. Predictor variables were initially handled as
block variables. Age and gender were grouped as the block variable
demographic, the BDI and HRSD scores were grouped as the block
variable mood and the MMSE, RAVLTDR, RCFTDR and
autobiographical memory measures were grouped as cognitive. The
models all fit the general formula (Function/QOL)=(
+ß1
demographic+ß2 mood+ß3 cognitive). If the
overall model was significant, we then examined which of the block variables
was significant. Finally, only if a block variable was significant did we
examine the component variables of the block to test their significance within
the full model and within univariate regressions. Statistical significance was
accepted for
set at 0.05. All tests were two-sided.
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RESULTS |
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Sixty-two patients (81%) met our definition of adequate treatment prior to ECT, and 39 (55%) and 47 (70%) met the definition at 2 weeks and 4 weeks, respectively (Prudic et al, 1996). Prescribed antidepressant regimens at 2 weeks included selective serotonin reuptake inhibitors (17 patients); venlafaxine (13 patients), atypical antidepressants (bupropion, mirtazapine or nefazodone; 22 patients), tricyclic antidepressants (12 patients, including 3 on lithium) and monoamine oxidase inhibitors (2 patients). The antidepressant regimens at 4 weeks were similar.
Forty-one participants from the full sample of 77 patients had complete data for every variable at every time point. Missing data from the other 36 patients were assumed to be missing at random; therefore imputation techniques were not employed. Prepost difference scores and regression models were examined for both all available data (full data-set) and for the 41 participants with a complete data-set. Statistical inference was the same for both the full data-set and the complete data-set; therefore, results are presented only for the full data-set.
The immediate post-ECT responder rate was 66%, with 37% of the responders relapsing within the first month after ECT. The sample showed improvement in every measure of mood, cognition, quality of life and function at both the 2-week and 4-week time points, except for the autobiographical memory test (which is only designed to reveal memory loss, not improvement). Further, the change in the nine variables showing improvement was statistically significant, except for the RAVLTDR (Table 2).
Although most patients experienced improved quality of life and function at the 2-week and 4-week assessments, a few had worse scores. There were 70 patients who had complete scores for baseline and 2-week measures of DLRF, RSO, IADL and PSMS, including 3, 8, 14 and 12 patients who had worse scores on the respective scales. There were 67 patients who had complete scores for baseline and 4-week measures of DLRF, RSO, IADL and PSMS, including 3, 8, 6 and 8 who had worse scores, respectively. Compared with patients with improved quality of life and function, patients with worse quality of life or function scores had lower baseline HRSD and RCFTDR scores, greater decrements in retrograde memory and less improvement in HRSD score.
All of the models of the change in DLRF and RSO scores were highly significant, and mood was the only significant block variable (Table 3). Fractionation of the mood block revealed that only the HRSD was statistically related to DLRF or RSO when the HRSD and BDI measures were both present in the models. Reductions in depression severity were associated with reductions in deficits in DLRF and RSO.
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The significant model of function was IADL at 2 weeks after ECT. Cognitive was the only block variable that was significant within that model. Further fractionation of cognitive showed that only the change in the MMSE score was related to the change in IADL score at 2 weeks (r=0.3, P<0.05; n=67). The contribution of the MMSE to the variance of IADL score could not be explained away as a confound of mood, as the change in MMSE score and the change in the HRSD score at 2 weeks were not related (r=70.1, P=0.38; n=69).
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DISCUSSION |
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The change in our quality of life measures (DLRF and RSO) was related to change in mood. This is consistent with earlier cross-sectional and longitudinal data which showed that mood, not cognition, was related to these two variables (McCall et al, 1999a, 2001; McCall & Dunn, 2003). The finding that only the change in HRSD score, not the change in BDI score, was significantly related to change in quality of life when both the HRSD and BDI were in the models may be explained by the use of the HRSD to determine response status to ECT. The decision to continue or stop ECT was in part related to change in the HRSD score, not the BDI score.
Although our sample showed improvement in both measures of function at the 2-week and 4-week time points (Table 2), our models could only predict the change in IADL at 2 weeks. Interestingly, change in IADL at 2 weeks was most closely related to change in cognition, not mood. In particular, improvement in the MMSE, but not any of the specific memory measures, was related to improvement in IADL at 2 weeks. This is consistent with our earlier finding that baseline IADL function in patients treated with ECT is related to the MMSE score but not to mood (McCall & Dunn, 2003).
Given the extensive research on cognitive deficits related to ECT, it may seem remarkable that our measures of global cognition, anterograde verbal memory and anterograde figural memory showed improvement at 2 weeks and 4 weeks after ECT compared with the pre-therapy baseline. However, cognitive improvement with ECT has been reported repeatedly over the past 40 years (Fink, 1979; Pisvejc et al, 1998). Cognitive problems may be an intrinsic part of depressive illness (Weingartner et al, 1981; King et al, 1991), and it is logical that treatment of depression should be associated with improvement on cognitive tests. Although the improvement on neuropsychological tests could be attributed to a practice effect, it is equally likely that it represents true improvement in cognitive efficiency in patients whose cognitive efficiency had been overtaxed by depression. Similar findings of improved cognition have been reported in stroke patients recovering from depression (Narushima et al, 2003) and in clinical trials of antidepressant medication in primary depression (Reynolds et al, 1987; Reifler et al, 1989; Newhouse et al, 2000; Cassano et al, 2002).
This study has some limitations. The number of participants was small, and there were some missing data. Still, the results from the all available (full) data-set led to the same inference as did the results of the complete data-set. Patients received naturalistic treatment during follow-up with a wide range of antidepressant medications in various dosages as prophylaxis against relapse. It is unclear how medication status might have affected mood, cognition, quality of life and function. Although the follow-up period was only a month long, the mood, cognitive and neurophysiological effects of ECT fade within weeks, perhaps with the exception of persistent autobiographical memory loss. Although autobiographical memory did not figure into any of our models during the first month of follow-up, it might be more important to assessment of quality of life months after ECT.
In summary, ECT is associated with improvement in quality of life, function, mood, anterograde memory and global cognitive status at 2 weeks and 4 weeks after this therapy. Most patients experienced improvement in quality of life and function. Change in perceived quality of life seems to be most influenced by changes in mood, whereas change in IADL function at 2 weeks was related to change in global cognition. The results are consistent with the premise that ECT produces a net improvement in health for most patients, and should help fill in the knowledge gap that led to the restrictive guidance on the use of ECT in the UK (National Institute for Clinical Excellence, 2003).
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication January 20, 2004. Revision received June 2, 2004. Accepted for publication June 26, 2004.