Effects of ECT and depression on various aspects of memory

Subjective cognitive complaints and subjective cognition following electroconvulsive therapy for depression: A systematic review and meta-analysis

BACKGROUND

Subjective cognitive complaints represent a leading reason for suboptimal prescription of electroconvulsive therapy, the most acutely effective treatment for depression. However, research findings regarding their presentation are conflicting.

OBJECTIVE

To describe, quantify and explain the variability in subjective cognitive complaints and subjective cognition following electroconvulsive therapy for depression.

METHODS

We searched systematically PubMed, Embase, PsycARTICLES, CINAHL and relevant reviews for research published from 1 January 1972 to 31 August 2020. We included all independent studies of patients whose subjective cognition was assessed following brief-pulse electroconvulsive therapy for depression. Three meta-analyses were conducted to quantify: (1) the prevalence of patients presenting with cognitive complaints following electroconvulsive therapy; (2) the pre-post electroconvulsive therapy change in subjective cognition and (3) the association between change in depressive symptoms and change in cognitive complaints. Effect sizes were calculated using random-effects models. Eight prespecified demographic and clinical moderators of between-study variability were assessed using sub-group analyses and meta-regressions.

RESULTS

Data from 72 studies including 5699 participants were meta-analysed. Weighted mean prevalence of patients with cognitive complaints was 48.1% (95% confidence interval = [42.3%, 53.9%]). The type of subjective measure used significantly impacted the pre-post electroconvulsive therapy change in subjective cognition, showing, respectively, large improvement (g = 0.81; 95% confidence interval = [0.59, 1.03]) after electroconvulsive therapy with the Squire Self-Rating Scale of Memory and small worsening (g = -0.48; 95% confidence interval = [-0.70, -0.26]) with 1-item memory scales. The strongest predictors of improved post-electroconvulsive therapy subjective cognition were increased age and larger post-electroconvulsive therapy decrease in depressive symptoms. The weighted mean correlation between pre-post electroconvulsive therapy decrease in depressive symptoms and pre-post electroconvulsive therapy decrease in cognitive complaints was 0.46 (95% confidence interval = [0.39, 0.53]).

CONCLUSION

Variability in subjective cognition following electroconvulsive therapy is mostly explained by the degree of post-treatment persisting depression and by the subjective assessment used. Scales measuring exclusively subjective worsening present limited clinical utility and instruments allowing the detection of both improvement and worsening in subjective cognition should be preferred.

A response to yet another defence of ECT in the absence of robust efficacy and safety evidence

It is estimated that electroconvulsive therapy is still administered to approximately a million people a year. It involves passing enough electric current through the human brain, eight to twelve times, to cause convulsions, in the hope of somehow alleviating emotional suffering, primarily depression. There have only ever been 11 placebo-controlled studies (where general anaesthesia is administered but the electric shock is withheld), all of which were pre-1986, had very small sample sizes and were seriously methodologically flawed. Five of these studies found no difference between the two groups at the end of treatment, four found ECT produced better outcomes for some patients, and two produced mixed results, including one where psychiatrists' ratings produced a difference, but the ratings of nurses and patients did not. In the 80 years since the first ECT no studies have found any evidence that ECT is better than placebo beyond the end of treatment. Nevertheless, all five meta-analyses relying on these studies have somehow concluded that ECT is more effective than placebo despite the studies' multiple failings. Meanwhile, evidence of persistent or permanent memory loss in 12% to 55% of patients has accumulated. Attempts to highlight this failure of ECT proponents to provide robust evidence that their treatment is effective and safe are routinely dismissed, diminished, denied and denounced. This paper responds to one such attempt, by Drs Meechan, Laws, Young, McLoughlin and Jauhar, to discredit two systematic reviews of the eleven pre-1986 studies, in 2010 and 2019, the latter of which also reviewed five meta-analyses that had ignored the studies' failings. The criticisms and claims of the recent crtiique of the two systematic reviews are examined in detail, by the first author of both reviews, for accuracy, relevance and logic. The critique is found to include multiple errors, misrepresentations, omissions, inconsistencies and logical flaws. It is concluded that Meechan et al. fail to make a fact-based, coherent argument against suspending ECT pending a series of large, carefully designed placebo-controlled studies to establish whether ECT does have any beneficial effects against which to weigh the significant established adverse effects.

A critique of narrative reviews of the evidence-base for ECT in depression

There has been recent debate regarding the efficacy of electroconvulsive therapy in the treatment of depression. This has been based on narrative reviews that contradict existing systematic reviews and meta-analyses. In this special article, we highlight the mistakes that occur when interpreting evidence using narrative reviews, as opposed to conventional systematic reviews and meta-analyses.

Does electroconvulsive therapy cause brain damage: An update

Electroconvulsive therapy (ECT) is an effective modality of treatment for a variety of psychiatric disorders. However, it has always been accused of being a coercive, unethical, and dangerous modality of treatment. The dangerousness of ECT has been mainly attributed to its claimed ability to cause brain damage. This narrative review aims to provide an update of the evidence with regard to whether the practice of ECT is associated with damage to the brain. An accepted definition of brain damage remains elusive. There are also ethical and technical problems in designing studies that look at this question specifically. Thus, even though there are newer technological tools and innovations, any review attempting to answer this question would have to take recourse to indirect methods. These include structural, functional, and metabolic neuroimaging; body fluid biochemical marker studies; and follow-up studies of cognitive impairment and incidence of dementia in people who have received ECT among others. The review of literature and present evidence suggests that ECT has a demonstrable impact on the structure and function of the brain. However, there is a lack of evidence at present to suggest that ECT causes brain damage.

Subjective memory complaints after electroconvulsive therapy: systematic review

Aims and methodFew studies have looked at subjective memory impairment from electroconvulsive therapy (ECT) after treatment completion. We aimed to systematically review all available evidence for subjective post-treatment effects. RESULTS: We included 16 studies in this review. There was considerable between-study heterogeneity in clinical population, ECT modality and assessment scales used. The most common assessment scale (eight studies) was the Squire Subjective Memory Questionnaire. The majority of studies reported an improvement in subjective memory after ECT, which correlated with improved depression scores. Subjective complaints were fewer in studies that used ultra-brief pulse ECT. Longer pulse widths were associated with more subjective complaints, as was female gender and younger age of treatment in the largest study.Clinical implicationsThere is considerable heterogeneity between studies, limiting meaningful conclusions. Ultra-brief pulse ECT appears to result in fewer subjective complaints.Declaration of interestNone.

Potential Role of Antipsychotic-Galantamine-Memantine Combination in the Treatment of Positive, Cognitive, and Negative Symptoms of Schizophrenia

Schizophrenia is, in part, a cognitive illness. There are no approved medications for cognitive impairments associated with schizophrenia (CIAS) and primary negative symptoms. Cholinergic and glutamatergic systems, alpha-7 nicotinic acetylcholine (α-7nACh) and N-methyl-D-aspartate (NMDA) receptors, kynurenic acid (KYNA), and mismatch negativity have been implicated in the pathophysiology of CIAS and negative symptoms. Galantamine is an acetylcholinesterase inhibitor that is also a positive allosteric modulator at the α4β2 and α7nACh receptors. Memantine is a noncompetitive NMDA receptor antagonist. Galantamine and memantine alone and in combination were effective for cognition in animals and people with Alzheimer's disease. The objective of this article is to critically dissect the published randomized controlled trials with galantamine and memantine for CIAS to highlight the efficacy signal. These studies may have failed to detect a clinically meaningful efficacy signal due to limitations, methodological issues, and possible medication nonadherence. There is evidence from a small open-label study that the galantamine-memantine combination may be effective for CIAS with kynurenine pathway metabolites as biomarkers to detect the severity of cognitive impairments. Given that there are no available treatments for cognitive impairments and primary negative symptoms in schizophrenia, testing of this "five-pronged strategy" (quintuple hypotheses: dopamine, nicotinic-cholinergic, glutamatergic/NMDA, GABA, and KYNA) is a "low-risk high-gain" approach that could be a major breakthrough in the field. The galantamine-memantine combination has the potential to treat positive, cognitive, and negative symptoms, and targeting the quintuple hypotheses concurrently may lead to a major scientific advancement - from antipsychotic treatment to antischizophrenia treatment.

Memantine in the prevention or alleviation of electroconvulsive therapy induces cognitive disorders: A placebo controlled trial

The purpose of this study was to evaluate the effect of memantine administration on the adverse cognitive effects of electroconvulsive therapy (ECT). Forty patients diagnosed with a major depressive disorder for which ECT was indicated as a treatment for their current episode were randomly allocated to either the memantine (5mg/day) group or the placebo group. All patients underwent the same protocol for anaesthesia and ECT procedures. The patients received memantine or the placebo for the whole period of ECT treatment, starting the day before ECT and continuing until the fourth session of ECT. The Modified Mental State Examination (MMSE) was used for the assessment of cognition before and after the trial. Regarding MMSE and item 3 MMSE (related to recent memory), the memantine group scored significantly higher at the end of ECT sessions than the control group (P=0.02, P<0.001, respectively). Our data support the hypothesis that memantine may reduce cognitive impairment following ECT. Memantine could be both a safe and well-tolerated treatment for use with ECT.

Two-year follow-up of cognitive functions in schizophrenia spectrum disorders of adolescent patients treated with electroconvulsive therapy

OBJECTIVE

The aim of the current study was to investigate the long-term cognitive effects of electroconvulsive therapy (ECT) in a sample of adolescent patients in whom schizophrenia spectrum disorders were diagnosed.

METHODS

The sample was composed of nine adolescent subjects in whom schizophrenia or schizoaffective disorder was diagnosed according to DSM-IV-TR criteria on whom ECT was conducted (ECT group) and nine adolescent subjects matched by age, socioeconomic status, and diagnostic and Positive and Negative Syndrome Scale (PANSS) total score at baseline on whom ECT was not conducted (NECT group). Clinical and neuropsychological assessments were carried out at baseline before ECT treatment and at 2-year follow-up.

RESULTS

Significant differences were found between groups in the number of unsuccessful medication trials. No statistically significant differences were found between the ECT group and the NECT group in either severity as assessed by the PANSS, or in any cognitive variables at baseline. At follow-up, both groups showed significant improvement in clinical variables (subscales of positive, general, and total scores of PANSS and Clinical Global Impressions-Improvement). In the cognitive assessment at follow-up, significant improvement was found in both groups in the semantic category of verbal fluency task and digits forward. However, no significant differences were found between groups in any clinical or cognitive variable at follow-up. Repeated measures analysis found no significant interaction of time×group in any clinical or neuropsychological measures.

CONCLUSIONS

The current study showed no significant differences in change over time in clinical or neuropsychological variables between the ECT group and the NECT group at 2-year follow-up. Thus, ECT did not show any negative influence on long-term neuropsychological variables in our sample.

Self-evaluation of the cognitive effects of electroconvulsive therapy

OBJECTIVES

Using standard self-evaluation questionnaires, numerous studies have found that subjective memory improves shortly after electroconvulsive therapy (ECT). This change covaries strongly with depression severity and is not associated with objective amnestic effects or treatment parameters. We examined subjective evaluations of ECT's cognitive effects using a novel interview that directly inquired about global impact, in contrast to the standard method of inquiring about specific aspects of cognition.

METHODS

We conducted a prospective, randomized, double-masked trial comparing the effects of pulse width (0.3 vs 1.5 milliseconds) and electrode placement (right unilateral vs bilateral) on cognitive outcomes. Subjective evaluations were obtained before and during the week after the randomized ECT course, using the Cognitive Failures Questionnaire, the Squire Memory Complaint Questionnaire, and the novel Global Self-Evaluation of Memory. An extensive neuropsychological battery was administered at these time points.

RESULTS

Cognitive Failures Questionnaire and Squire Memory Complaint Questionnaire scores improved at post-ECT relative to pre-ECT, strongly covaried with depression severity (24-item Hamilton Depression Rating Scale scores) but not with objective amnestic deficits or treatment parameters. In contrast, the treatment conditions differed in post-ECT Global Self-Evaluation of Memory scores, and these scores were associated with objective amnestic effects.

CONCLUSIONS

In contrast to standard methods, direct questioning about global impact resulted in more negative views about ECT's cognitive effects, concordance with objective cognitive measures, and differences among treatment conditions. Patients may be more accurate in their assessment of ECT's adverse effects than had previously been suggested.

Electroconvulsive therapy: a theory for the mechanism of action

Cases of memory deficits after electroconvulsive therapy (ECT) have been widely reported particularly short-term memory and to a lesser extent, long-term and autobiographical memory. Explanations for the mechanisms of ECT action have largely been limited to studies of the effect on brain metabolism, neurochemistry, and areas of the brain such as the hippocampus and frontal lobes. However, passing a current of electricity through the brain is clearly a holistic treatment, and consequently, a holistic theory may offer a better understanding of ECT action. Because of its effect on memory systems both positive and negative, it is possible that aspects of memory function could hold the key in explaining how and why successful ECT treatment functions. It will be argued that successful ECT treatment is effective because it facilitates and restores the function of specific memory systems that are deficient in the course of a severe depressive episode. It is these memory systems that link a person to the very essence of their existence and personal identity.

The impact of galantamine on cognition and mood during electroconvulsive therapy: a pilot study

OBJECTIVES

The purpose of this study was to: (1) assess the effectiveness of galantamine in the prevention of cognitive impairments during ECT treatment and (2) to explore the safety and tolerability of galantamine during ECT treatment.

METHODS

Nine consecutive ECT patients were given galantamine 4 mg bid throughout the course of their ECT treatments followed by a second cohort of eight consecutive ECT patients who did not receive galantamine. Objective measures of cognitive functioning and depression severity were performed pre-ECT and post-ECT. Subjective ratings of depression, confusion, and side effects were obtained weekly.

RESULTS

The two groups were similar in age, gender and admission Global Assessment Functioning (GAF) scores. There were no significant between group differences found with regards to mean seizure duration, energy administered to induce seizures, blood pressure, or heart rate during and post-ECT treatment. None of the patients discontinued galantamine due to side effects and there were no severe adverse drug reactions. Patients receiving galantamine performed significantly better on delayed memory and abstract reasoning following ECT. The galantamine group showed a greater but non-significant mood improvement (repeated measure ANOVA).

CONCLUSIONS

Our data support the hypothesis that galantamine may reduce cognitive impairment during ECT, especially with regards to new learning. In addition, galantamine may also enhance the antidepressant action of ECT. Galantamine was both safe and well tolerated during ECT.

Neuropsychological effects and attitudes in patients following electroconvulsive therapy

The current study examined the effects of electroconvulsive therapy (ECT) on neuropsychological test performance. Forty-six patients completed brief neuropsychological and psychological testing before and after receiving ECT for the treatment of recalcitrant and severe depression. Neuropsychological testing consisted of the Levin Selective Reminding Test (Levin) and Wechsler Memory Scale-Revised Edition (WMS-R). Self-report measures included the Beck Depression Inventory (BDI), the Short-Term Memory Questionnaire (STMQ), and several other measures of emotional functioning and patient attitudes toward ECT. The mean number of days between pre-ECT and post-ECT testing was 24. T-test revealed a significant decrease in subjective ratings of depression as rated by the BDI, t(45) = 9.82, P < 0.0001 (Pre-BDI = 27.9 +/- 20.2; post-BDI = 13.5 +/- 9.7). Objective ratings of memory appeared impaired following treatment, and patients' self-report measures of memory confirmed this decline. More specifically, repeated measures MANOVA [Wilks Lambda F(11,30) = 4.3, p < 0.001] indicated significant decreases for measures of immediate recognition memory (p < 0.005), long-term storage (p < 0.05), delayed prose passage recall (p < 0.0001), percent retained of prose passages (p < 0.0001), and percent retained of visual designs (p < 0.0001). In addition, the number of double mentions on the Levin increased (p < 0.02). This study suggests that there may be a greater need to discuss the intermittent cognitive risks associated with ECT when obtaining informed consent prior to treatment. Further that self-reports of cognitive difficulties may persist even when depression has remitted. However, patients may not acknowledge or be aware of changes in their memory functioning, and post-ECT self-reports may not be reliable.

Cognitive functions after only one ECT session: a controlled study

The aim of the study was to determine the effects of one electroconvulsive therapy (ECT) session on learning, attention, and frontal and visuospatial functions. Twenty-four psychiatric patients receiving maintenance ECT participated in the study. The 12 patients in the experimental group were assessed before and 90 min after the ECT session. The twelve patients in the control group were assessed on arrival at the hospital and 90 min afterwards. They were then given their ECT session. The experimental group did not show significant learning, attention or frontal decline in the second assessment after the ECT session, in comparison with the control group. However, visuospatial ability was lower in experimental patients' second assessment than it was in the control group's second assessment. This preliminary study showed that there was no significant clinical cognitive decline in psychiatric patients 90 min after a single ECT session. However, patients presented visuospatial dysfunction, suggesting that ECT sessions may cause some acute, mild dysfunction of right hemispheric cognitive functions.

The effect of electroconvulsive therapy on autobiographical memory: a systematic review

OBJECTIVES

In the last 20 years, an increasing number of articles have been published about effects of electroconvulsive therapy (ECT) on memory. Here, we review autobiographical memory studies in particular because there have been conflicting reports about the extent and persistence of ECT effects and the period before treatment from which memories are most likely to be affected.

METHODS

Five psychological and medical databases (MEDLINE, PubMed, PsychINFO, ScienceDirect, and Web of Knowledge) were searched from 1980 to 2007, yielding 15 studies of ECT and autobiographical memory.

RESULTS

Evidence suggests that autobiographical memory impairment does occur as a result of ECT. Objective measures found memory loss to be relatively short term (<6 months posttreatment), whereas subjective accounts reported amnesia to be more persistent (>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.

[Adverse cognitive effects and ECT]

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.

The subjective experience of patients who received electroconvulsive therapy

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.

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

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.

Cognitive deficits in depression: possible implications for functional neuropathology

BACKGROUND

While depression is known to involve a disturbance of mood, movement and cognition, its associated cognitive deficits are frequently viewed as simple epiphenomena of the disorder.

AIMS

To review the status of cognitive deficits in depression and their putative neurobiological underpinnings.

METHOD

Selective computerised review of the literature examining cognitive deficits in depression and their brain correlates.

RESULTS

Recent studies report both mnemonic deficits and the presence of executive impairment--possibly selective for set-shifting tasks--in depression. Many studies suggest that these occur independent of age, depression severity and subtype, task 'difficulty', motivation and response bias: some persist upon clinical 'recovery'.

CONCLUSIONS

Mnemonic and executive deficits do no appear to be epiphenomena of depressive disorder. A focus on the interactions between motivation, affect and cognitive function may allow greater understanding of the interplay between key aspects of the dorsal and ventral aspects of the prefrontal cortex in depression.

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

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.

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

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 ECT.

Electroconvulsive therapy and memory loss: a personal journey

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.

Frontal lobe dysfunction in obsessive-compulsive disorder and major depression: a clinical-neuropsychological study

Neuropsychological findings support a hypothesized relationship between obsessive-compulsive disorder (OCD) and the frontal lobe. The aim of the present study was to compare findings of neuropsychological tests of frontal lobe function in 28 OCD patients and 29 patients with major depressive disorder (MDD), all diagnosed according to DSM III-R criteria. The patient groups were homogeneous for educational level, handedness, duration of illness, and sex distribution. All 57 subjects received a battery of tests sensitive to frontal lobe dysfunction as well as the Wechsler Memory Scale (WMS). Clinical symptomatology in the MDD and OCD groups was assessed with the Hamilton Rating Scale for Depression and the Yale-Brown Obsessive-Compulsive Scale, respectively. The only significant difference between the two diagnostic groups for any of the neuropsychological indices, with age as a covariate, was in the Object Alternation Test, in which OCD patients had a significantly higher number of perseverative responses. Test performances were not correlated with clinical symptomatology or severity of illness. Our preliminary results confirm the hypothesis that there is a selective impairment of orbito-frontal cortex in OCD and seem to exclude the existence of specific frontal lobe dysfunction in MDD, even though the two disorders show clinical similarities.

Depression in schizophrenia: I. Association with neuropsychological deficits

BACKGROUND

The presence of depression in schizophrenia has been well described with regard to stage and symptoms of illness; however, little is known about the possible etiology.

METHODS

In an effort to advance the understanding of the neurobiology of depression in schizophrenia, we grouped patients with schizophrenia based on their ratings on the 21-item Hamilton Depression Rating Scale. There were 63 patients (35 men, 28 women) in the high (> or = 18) depression group and 81 patients (52 men, 29 women) in the low (< 18) depression group. The groups were compared in demographic, clinical, and eight neuropsychological domains.

RESULTS

The two groups differed in age at onset of illness, severity of delusions, and performance in a single neuropsychological domain: attention. The specific component of impaired attention was vigilance, with poorest performance seen in women with higher depression scores.

CONCLUSION

The presence of specific attentional impairment associated with depressive symptoms in schizophrenia is consistent with the hypothesis of frontal lobe dysfunction in depression, because these regions have been implicated in attentional processes.

Subjective memory complaints prior to and following electroconvulsive therapy

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.

The neuropsychology of depression and its implications for cognitive therapy

The past few years have witnessed a growing interest in the specialty of neuropsychology as well as continued support for cognitive therapy of depression. The purpose of this paper is the examination of the neuropsychology of depression and its implications for A. T. Beck's cognitive theory and therapy of depression ([1963] "Thinking and Depression: Idiosyncratic Content and Cognitive Distortions," Archives of General Psychiatry, Vol. 9, pp. 324-333; [1964] "Thinking and Depression," Archives of General Psychiatry, Vol. 10, pp. 561-571; [1967] Depression: Clinical, Experimental, and Theoretical Aspects, New York: Harper & Row). Specifically, the neuropsychological and cognitive theory and therapy literatures related to depression are reviewed followed by an integration of these areas. Neuropsychological evidence is presented that both supports cognitive theory and therapy of depression and helps explain why such therapy may prove ineffective in treating depression. Implications for clinical practice, including neuropsychological assessment of depressives, and potential future research directions are also provided.

Cognitive function in depression: its relationship to the presence and severity of intellectual decline

Cognitive dysfunction is an integral feature of depression, in some cases of sufficient severity to warrant a diagnosis of dementia. There has been little systematic investigation of whether cognitive dysfunction is an inevitable consequence of depression, or is specific to a subgroup of depressed patients. Related to this is the distribution of cognitive dysfunction, whether there is a continuum of impairment or a distinct demented subgroup. Finally, there is the question of which aspects of cognitive function are most sensitive to the intellectual decline seen in depression. A study is described which addresses these issues. The distribution of global cognition was found to be normally distributed in the sample of 29 patients assessed. Based on this distribution and the scores of a control sample, the patients were classified as unimpaired, borderline or impaired. Two sets of independent comparisons were carried out. First, the unimpaired depressed patients were compared to matched non-depressed controls. Significant deficits were found on a range of neuropsychological measures covering aspects of language function, memory, both recall and recognition, attention and behavioural regulation. These same patients were also compared with two groups of matched depressed patients, with varying degrees of global cognitive impairment. In general, the cognitive measures showed a gradient of dysfunction across the three patients groups. Significant differences between the depressed groups were shown on measures of immediate recall, attention and behavioural regulation. The possible significance of attentional factors for the observed memory dysfunction is discussed.

Experimental evidence for two dimensions of cognitive disorders in depressives

Three neuropsychological tests (Rey's auditory verbal learning test, word fluency and signal detection test for words) were administered to 36 depressed patients (medicated and non-medicated) and 26 controls and compared to scale scores for depression severity and psychomotor retardation to examine how retardation was related to cognitive performance. As expected, compared to controls depressives exhibited non-specific "cognitive inefficiency", that is, consistently deficient performance in all cognitive tasks. Results on all three tests were correlated with one other and with depressive severity (measured by the Montgomery & Asberg Depression Rating Scale, MADRS). One notable exception, however, was the score for commission errors ("false alarms") in the signal detection test, which correlated negatively with psychomotor retardation (measured by a subscale of the Salpétrière Retardation Rating Scale, SRRS) but not at all with depressive severity. Lack of commission errors thus seemed to index a dimension of retardation of ideation that seemed distinct from the non-specific cognitive inefficiency dimension. Conversely, omission errors in the same test strongly correlated with the other two cognitive tests and with depressive severity but not with psychomotor retardation. Cognitive performance in depressives might thus be explainable in terms of two overlapping dimensions of depressive pathology (global cognitive impairment vs. specific effect of retardation). Further studies with non-medicated patients are needed to determine to what extent these findings may be due to medication effects.

Effects of depression on memory performance and metamemory in children

OBJECTIVE

To investigate the effects of depression on memory performance and metamemory in children.

METHOD

Performance on automatic memory tasks (frequency of occurrence), effortful memory tasks (Children's Auditory Verbal Learning Test), and a Metamemory Battery were examined in 21 unmedicated, depressed children and 21 nondepressed controls (matched for age, gender, and full-scale IQ). Subjects were divided into three groups based on depression severity (high depressed, low depressed, nondepressed).

RESULTS

High depressed patients demonstrated performance deficits relative to nondepressed and low depressed children on the Children's Auditory Verbal Learning Test, Immediate Recall trial. Both groups of depressed children performed more poorly on the Metamemory Battery when compared to nondepressed children. Severity of depression differentiated overall performance. Metamemory performance of depressed subjects indicates possible difficulty with overestimation of memory abilities. No differences were found on automatic memory task performance.

CONCLUSIONS

Memory impairment in depression varies as a function of severity and may be evident only when a certain level of depression is reached. Overestimation of memory ability by depressed children may be an attempt to compensate for feelings of inadequacy or inferiority. It may also lead depressives to use poor judgment in selecting appropriate solutions for problems. Targeting these cognitive distortions could be a focal point of clinical and educational interventions.

Does mood-congruence or causal search govern recall bias? A test of life event recall

Recall bias has been hypothesized to occur as a function of mood congruence or causal-search related mechanisms. This study tested whether either mechanism related to recall of stressful life events over a year. Respondents consisted of 136 cases suffering from chronic facial pain and 131 acquaintance controls. After reporting life events for 1 year at monthly intervals, respondents attempted to recall these same events at year-end. Mood and likelihood of engaging in causal search were also ascertained at year-end. Results showed no effect of mood congruence or causal search on recall of event occurrence. However, mood did influence subjective appraisal of those events that were recalled. In addition, a significant mood-related memory deficit was detected. Findings indicate that mood-related memory deficit may reduce effect sizes artifactually. Furthermore, when assessing effects of recall bias, recall of event occurrence must be considered separately from subjective appraisal of event characteristics.

The nature and time course of cognitive side effects during electroconvulsive therapy in the elderly

Cognitive and clinical changes during hospitalization were examined in 48 elderly patients with major depression treated with electroconvulsive therapy (ECT) and 55 elderly depressed patients not treated with ECT. Cognitive changes with ECT involved orientation, attention and calculation, and recall. The maximal decrement during ECT averaged 3 points on the Mini-Mental State Examination and occurred after two thirds of the treatments were administered. Baseline cognitive values returned by time of discharge. The affective symptoms improved throughout the course of treatment and remained improved while cognition returned to normal. Patients not receiving ECT showed slightly improved cognitive performance during hospitalization and small, gradual, clinical improvement.

The subcortical dysfunction hypothesis of memory deficits in depression: neuropsychological validation in a subgroup of patients

The subcortical dysfunction hypothesis of verbal learning and memory deficits in depression was evaluated by comparing the memory test profiles of unipolar depressives (n = 40) and bipolar depressives (n = 9) with those of patients with a prototypical subcortical dementia (Huntington's disease, HD), patients with a prototypical cortical dementia (Alzheimer's disease, AD), and normal controls. In a discriminant function analysis that well-differentiated the HD, AD, and normal subjects, it was found that 28.6% of the depressed patients were classified as HD patients (DEP-HD subjects), 49.0% were classified as normals (DEP-N subjects), none were classified as AD patients, and 22.4% were not well-classified. The DEP-HD group closely resembled the HD group on additional indices of verbal learning and memory, and differed from the DEP-N group, which strongly resembled the normal control group. DEP-N patients also performed significantly better than DEP-HD patients on a number of other neuropsychological tests (e.g., WAIS-R Digit Symbol, category fluency, Trail Making Test Part B). The findings provide support for the subcortical dysfunction hypothesis, but only for a subgroup of depressed patients. Implications for differentiating depressive "pseudodementia" from AD are discussed.

Cognitive function in major depression

Forty patients with a major depressive episode were divided into equal endogenous and neurotic sub-groups using the Newcastle scale. They were all rated on the 17-item Hamilton scale and with a variety of neuropsychological tests. They were compared with 20 age- and education-matched control subjects. Both endogenous and neurotic groups had impaired memory function on the auditory verbal learning test; recall and recognition were equally impaired suggesting that effort was not a major determinant of performance. The endogenous group was more impaired on digit symbol substitution and the Trail making test (A and B). Impairment was correlated with symptom scores on the Hamilton and Newcastle scales, even after allowing for the effect of age. It is concluded that the conventional distinction between organic and functional impairment breaks down in severe depressive illness. The implications of this for clinical neuropsychological testing and the anatomy of the brain dysfunction in depressive illness are discussed.

Effects of major depression on estimates of intelligence

This study examined whether patients with major depressive disorder manifest deficits in intelligence during affective episodes and following clinical improvement. WAIS-R scores were contrasted in 100 patients in an episode of major depression with 50 normal controls, matched to the patient sample in terms of demographic variables and estimates of premorbid IQ. The groups were equivalent in verbal IQ, but, in line with previous studies, the depressed patients had a pronounced deficit in performance IQ. A patient subsample was administered the WAIS-R under unlimited time conditions to determine whether the time constraints of performance IQ subtests contributed to the magnitude of the verbal-performance IQ discrepancy. This discrepancy was only slightly reduced with untimed scoring. Subgroups of depressed patients were retested with the WAIS-R within one week (n = 26) or two months (n = 33) following treatment with electroconvulsive therapy. In both subsamples, IQ scores were improved at posttreatment testing relative to pretreatment, but with little change in the verbal-performance IQ discrepancy. These and related findings suggested that a performance IQ deficit is characteristic of depressed patients regardless of affective state.

Memory and hedonic tone: 'personality' or 'mood' congruence?

Four groups of healthy women matched for age and IQ were reliably classified on the Eysenck Personality Questionnaire as being either high or low in extraversion or neuroticism. As part of a larger research project, each participant was administered a range of psychometric measures together with three paired-associate learning lists varying in hedonic tone and difficulty levels together with the Beck Depression Inventory. Performance on the hedonic lists covaried with personality categories but, unlike what typically obtains in clinical patients, less association emerged between performance and mood states. Performance was particularly polarized in women scoring high in neuroticism but low in extraversion. Speculations about the apparent correlates of so-called mood congruence in healthy subjects are put forward and parallels are drawn with studies reporting the phenomenon in clinically depressed patients.

Memory impairment in schizophrenia: its extent, affiliations and neuropsychological character

In a sample of 60 schizophrenic patients encompassing all grades of severity and chronicity memory impairment was found to be prevalent, often substantial, and disproportionate to the overall level of intellectual impairment. The deficits were not easily attributable to poor cooperation, attention or motivation; nor were they related to neuroleptic or anticholinergic medication. Memory impairment was significantly associated with severity and chronicity of illness and also with negative symptoms and formal thought disorder. There was evidence from the sample as a whole, and from a more detailed examination of five patients with relatively isolated deficits, that schizophrenic memory impairment conformed to the pattern seen in the classical amnesic syndrome. Additionally, there was preliminary evidence for a marked deficit in semantic memory.

Dichotic perception and memory following electroconvulsive treatment for depression

Verbal and visuospatial memory and dichotic listening performance were examined in 15 acutely depressed patients with no history of ECT, 17 depressed patients currently in remission, 15 remitted depressed patients who had received ECT six months or more in the past, and 20 normal controls. The neuropsychological functioning of an additional group of 10 acutely depressed patients was also studied before and two weeks after ECT. The results revealed some evidence of logical and autobiographical memory impairment two weeks following ECT, but no evidence that ECT impaired dichotic listening ability. Rather, a normalisation of hemispheric laterality was apparent on the dichotic listening task following ECT and the concomitant relief from depression. There was also no evidence of cognitive dysfunction on any task in individuals who were tested six months or more following their last ECT treatment.

Depression in late life: an update

Clinical and basic research units depressive disorders in late life have expanded our knowledge base appreciably in recent years. In the process, some clinical impressions have been confirmed (e.g., the association of depression and physical disorders); others have been refuted (e.g., depression increases with age); and now phenomena have been identified (e.g., the discovery of leukoencephalopathy in depressant elders who respond to ECT). The field of study now encompasses a range from neurobiology to sociocultural factors. The latter twentieth century is an exciting and optimistic era for clinicians working with depressed elders. As Sir Martin Roth has often said, "Where there is depression in late life, there is hope."

Sources of public prejudice against electro-convulsive therapy

Recent legislation in NSW betrays a prejudice against electro-convulsive therapy. Factors probably contributing to popular prejudice against ECT are discussed.

Distinct memory impairments following electroconvulsive therapy and imipramine

Memory functioning was assessed in 26 unmedicated patients with major depressive disorder (DSM-III) who were then administered either bilateral electroconvulsive therapy (ECT) (N = 16) or imipramine 200 mg per day (N = 10). The subjects were retested following seven ECT administrations or 21 days of imipramine treatment respectively. The retrograde memory tasks included recall of public and autobiographic events. The anterograde memory tasks included an immediate memory task, a verbal paired-associates recall task, and a non-verbal figure reproduction task. Depression was significantly improved in the ECT-treated subjects but not in those administered imipramine. Both ECT- and imipramine-treated patients showed a deficit in recent anterograde memory relative to their pretreatment performance, but no deficit in immediate memory. ECT-treated patients also had a significant and well-characterized impairment in retrograde remote memory. By contrast, imipramine-treated patients did not show a retrograde memory impairment which could be explained by treatment. The results suggest qualitatively different memory deficits produced by ECT and imipramine.

Inadequate provision for electroconvulsive therapy in the New South Wales Mental Health Act 1983

Division 2 of Part X of the NSW Mental Health Act 1983 lays down a set of conditions which must be satisfied before electroconvulsive therapy (ECT) can be given. These provisions are too restrictive and would deny ECT to a considerable proportion of the patients who are most likely to benefit from it. For many of them it would be the only effective treatment. Principles which should govern the authorisation of ECT are proposed.

Geriatric depression

Depression in later life can present unique clinical and therapeutic challenges. Phenomenology is often atypical and the concurrence of physical illness can confound both diagnosis and treatment. A review of current knowledge about epidemiology, pathogenesis, clinical features, and therapeutic issues is presented.