BJPsych Open (2020)

6, e40, 1–7. doi: 10.1192/bjo.2020.17

Review

Cognitive side-effects of
electroconvulsive therapy: what are
they, how to monitor them and what to
tell patients
Richard J. Porter, Bernhard T. Baune, Grace Morris, Amber Hamilton, Darryl Bassett, Philip Boyce,
Malcolm J. Hopwood, Roger Mulder, Gordon Parker, Ajeet B. Singh, Tim Outhred,
Pritha Das and Gin S. Malhi

Background impairment, particularly of new learning, cannot occur in indivi-

Electroconvulsive therapy (ECT) is recommended in treatment duals, particularly those who are at greater risk. Therefore,
guidelines as an efficacious therapy for treatment-resistant monitoring is still important. Evidence suggests that ECT does
depression. However, it has been associated with loss of auto- cause deficits in autobiographical memory. The evidence for
biographical memory and short-term reduction in new learning. schedules of testing to monitor cognitive side-effects is currently
limited. We therefore make practical recommendations based
Aims on clinical experience.
To provide clinically useful guidelines to aid clinicians in inform-
ing patients regarding the cognitive side-effects of ECT and in Conclusions
monitoring these during a course of ECT, using complex data. Despite modern ECT techniques, cognitive side-effects remain
an important issue, although their nature and degree remains to
Method be clarified fully. In these circumstances it is useful for clinicians
A Committee of clinical and academic experts from Australia and to have guidance regarding what to tell patients and how to
New Zealand met to the discuss the key issues pertaining to ECT monitor these side-effects clinically.
and cognitive side-effects. Evidence regarding cognitive side-
effects was reviewed, as was the limited evidence regarding how Keywords
to monitor them. Both issues were supplemented by the clinical Depression; cognition; electroconvulsive therapy; neuro-
experience of the authors. psychological tests; memory disorders.

Results Copyright and usage

Meta-analyses suggest that new learning is impaired immedi- © The Author(s) 2020. This is an Open Access article, distributed
ately following ECT but that group mean scores return at least to under the terms of the Creative Commons Attribution licence
baseline by 14 days after ECT. Other cognitive functions are (http://creativecommons.org/licenses/by/4.0/), which permits
generally unaffected. However, the finding of a mean score that unrestricted re-use, distribution, and reproduction in any
is not reduced from baseline cannot be taken to indicate that medium, provided the original work is properly cited.

Despite considerable advances in the practice of electroconvulsive and cognitive side-effects. Evidence regarding cognitive side-
therapy (ECT), the benefits of this treatment remain a balance effects was reviewed, as was the limited evidence regarding how to
between effectiveness and the risk of cognitive side-effects.1 It is monitor them. Both issues were supplemented by the clinical
therefore important for clinicians not only to understand the clinical experience of the authors.
indications and likely clinical benefits of ECT, but also to have a
clear understanding of the cognitive side-effects. However, the com-
plexities of research evidence, different ECT techniques and differ- Results
ing cognitive tests and functions, make it increasingly difficult for
busy clinicians to understand the latest evidence. Therefore, the What are the cognitive side-effects of ECT?
aim of this paper is to assist clinicians by briefly discussing the evi- Several important factors determine the risk of cognitive side-effects
dence regarding the cognitive side-effects of ECT. We then consider of ECT. These can be divided into the following, all of which interact
whether screening of cognition during ECT can be developed in to determine risk.
order to detect problems at an early stage and how this might be
done. Finally, based on the current evidence, the paper outlines (a) The domain of cognitive function that is being considered.
what information clinicians should present to patients regarding (b) ECT treatment parameters – electrode placement, dose of elec-
the potential cognitive side-effects of ECT. The issue of cognitive tricity, pulse width, treatment frequency, number of treatments.
side-effects of ECT is illustrated using the example of treatment of (c) Individual patient factors.
major depressive episodes (MDEs), although similar issues probably
apply to other diagnostic groups. What domains of cognitive function are affected?
The meta-analyses of Semkovska and colleagues2,3 examined pooled
data from existing studies. These divided functioning into separate
Method cognitive domains and examined subacute (0–3 days), short-term (4
days–14 days) and long-term (14 days–2 years) effects. Though
A Committee of clinical and academic experts from Australia and these meta-analyses have provided the most comprehensive over-
New Zealand met to the discuss the key issues pertaining to ECT view to date, the results are complex and differences between the

1
Porter et al

effects on different cognitive tasks may relate to properties of the some patients report that it does and it seems unlikely that lost
tasks being employed rather than being a function of the sensitivity memories could return spontaneously after this point. Although
of that domain of cognitive function to disruption by ECT per se. It studies report loss of autobiographical memory as a mean, com-
is also important to recognise that cognitive tasks inevitably rely on pared with baseline, identification of individuals who experience
a range of functions and that it is difficult to separate these out. For particularly severe loss has rarely been done. Where this has been
example, memory tests inevitably also load on executive and atten- done, there is evidence that females and those receiving bilateral
tional function whereas tests of attention load on executive function ECT are more at risk.11
and vice versa. A simplified summary of the data is given below.
Subjective impairment. Studies of subjective reports of cognitive
Non-memory cognition. In the subacute period following ECT (0– side-effects show varying percentages of patients who complain of
3 days), tests of executive function and processing speed were ‘memory loss’, depending on a range of factors, including who inter-
impaired compared with baseline. However, tests of attention viewed them (Rose et al8). A recent review suggests that 60% of
were not impaired at this time point.2 When measured between 4 patients report memory problems, with 40% reporting that these
and 14 days most tests had improved significantly compared with lasted from several weeks to several years.12 However, most of the
baseline and none were significantly below baseline. The improve- patients involved in these studies received bilateral ECT, limiting
ment is likely to have been a result of successful treatment of the generalisation to other forms of ECT.
depressive illness as studies suggest that in very severe depression, Subjective assessment of cognitive problems following ECT,
a high percentage of patients have very significant cognitive impair- usually assessed using detailed questionnaires, such as the
ment.4–6 Cognitive Failures Questionnaire,13 correlates poorly with objective
Longer term, with a wide range of follow-up intervals (2 weeks deficits. Subjective impairment often reduces throughout the course
to 2 years), there was no evidence of impairment in tests of non- of treatment – tracking closely with clinical response. However,
memory cognition.2 The only caveat to this may involve the use studies that used a simple question or seven-point Likert scale
of sine wave ECT machines (discussed below). asking patients whether ECT ‘helped’ or ‘hurt’ their memory
showed that scores on this scale declined (i.e. ECT ‘hurt’ memory
Anterograde memory. Individual studies show that there was on average) and this, in contrast with more complex assessment,
impairment on tests of anterograde memory from early in a course correlated with loss of autobiographical memory.14,15,16
of ECT7 and meta-analyses suggest that this was still impaired suba-
cutely (0–3 days) but returned to baseline (once again a baseline that
may have been adversely affected by depression) between 4 and 14 How do treatment parameters affect cognitive side-
days after the end of the course of ECT.2 The degree of initial impair- effects?
ment depends on treatment and patient factors considered below. Modern ECT can be broadly divided into three types depending on
Once again, the data refers to mean values and compares perform- placement of electrodes and the pulse width of electricity
ance with a baseline, which is likely to be reduced secondary to the administered.
cognitive effects of severe depression itself.5
(a) Bilateral ECT (bitemporal or bifrontal electrode placement)
Beyond 14 days, there was no evidence of objectively assessed
using a brief pulse width.
impairment.2
(b) Unilateral (usually right) (RUL) ECT using a brief pulse
A caveat, which applies to all domains of cognitive function, is
width – with pulses of electricity usually having a duration
that although studies reporting the results of objective cognitive
of 0.5–1 mS.
tests present mean results, the finding of no mean change from base-
(c) Unilateral using an ultra-brief pulse width (UB-RUL), usually
line does not necessarily mean that no patients experienced a clin-
0.25–0.3 mS.
ically significant reduction in function. If, for instance, some
patients improve greatly from baseline, a lack of mean change Although overall efficacy increases from UB-RUL to RUL to
implies that some patients deteriorate. This is important to bear bilateral,17,18 so do cognitive side-effects. In particular, reduction
in mind when explaining risk on a case by case basis in clinical prac- in scores on the CUAMI immediately following ECT follow the
tice. Studies have rarely provided analysis on an individual level. We same gradient and are greater than for controls measured over the
recommend that future studies provide this type of analysis in order same time period. For each treatment, the dose of electricity
for clinicians to be able to give information to patients regarding the above threshold also has an impact on the degree of cognitive
percentage risk of significant decline. side-effects (the higher the dose the greater the effects), including
the long-term loss of autobiographical memory.19
Retrograde memory. When patients report cognitive side-effects
it is often loss of autobiographical memory (i.e. loss of memory Frequency of treatment
for events that the person has experienced) that are reported.8
Few studies have examined the effects on cognitive side-effects of
However, both episodic memory (memory for experiences) and
differences in frequency of treatment, in an RCT design.
semantic memory (memory for facts) are affected. Retrograde
Although bilateral ECT three times a week provided more rapid
amnesia for non-personal information has also been reported.9
relief, patients had more severe cognitive side-effects.20 In either
Loss of memory in both areas may be distressing and functionally
case, effects are limited. A meta-analysis2 also showed some neuro-
impairing. Objective testing of the loss of autobiographical
cognitive tests to be differentially affected by frequency when com-
memory (personal memories – including both episodic and seman-
paring results between studies (i.e. not randomised within studies),
tic), usually using the Colombia University Autobiographical
but only in the short term (4–14 days). This analysis did not con-
Memory Interview (CUAMI), has shown that the degree of loss
sider retrograde amnesia.
differs depending on treatment parameters and that it exceeds the
normal decay of memories over time in healthy matched partici-
pants. Furthermore, in studies where it is objectively measured for Duration of treatment
at least 1 year10 this loss has been found to persist. Whether it con- ECT given at a frequency of two or three times a week causes
tinues for longer than 1 year is not clear from objective studies, but increasing cognitive side-effects as the course lengthens.7 What

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 Cognitive side‐effects of electroconvulsive therapy

has not been systematically studied is whether for most patients often have learnt of this through media and the Internet, it is
there is an acceleration of cognitive decline at a particular point in reassuring if this is addressed repeatedly throughout the course of
the course of treatment. An often recommended maximum ECT. Indeed, several practice guidelines have specifically recom-
number of treatments is 12 based on the fact that most patients mended routine assessment of cognitive function during a course
who respond do so within that number of treatments. The mean of ECT29,30 (see Rasmussen31 for a comprehensive review of recom-
number of treatments in most research studies and in clinical prac- mendations). However, there are several problems with systematic
tice is between 8 and 10. Where UB-RUL is used the mean number cognitive monitoring.
of treatments may be slightly greater.21 Our clinical experience is
(a) Testing patients at baseline with particularly severe depression
that at some point later in a course of ECT (particularly bilateral)
and even psychotic or catatonic features is difficult and often
cognitive side-effects sometimes rapidly become more problematic
simply not feasible.
(i.e. there is a threshold effect). Therefore, wherever clinically pos-
(b) Repeat testing can be problematic as patients will remember
sible, prolonged courses (>12 treatments) should be avoided and
tasks and may develop compensatory strategies over time.
cognitive effects need to be monitored closely if the course is
(c) In many centres resources are limited and the regular use of a
extended.
detailed cognitive test battery is impractical.
Maintenance treatment Further research is needed to determine optimal testing to monitor
A related question is whether maintenance treatment causes pro- cognitive side-effects. Ideally it should be demonstrated that early
gressive cognitive side-effects. Pertinent to this issue is, the fre- changes in monitoring tests correlate with later changes and that
quency of maintenance treatment which, by convention and a patient with a large reduction in function on a particular test
empirically, is often monthly, often reached by gradual tapering of after two to three sessions is likely to go on to develop even
frequency from an index course. Individual case reports have sug- greater and possibly clinically significant and distressing impair-
gested that cognitive side-effects do not accumulate in such ment later in the course of ECT treatment. Furthermore, there is
instances22 but the evidence is limited and there is no good evidence no research that clearly indicates at what level of reduction from
regarding the impact of treatment interval. Our clinical experience baseline concern should be raised. However, even without clear
is that shorter intervals, particularly less than 3 weeks, can be prob- research evidence at this point, there are several potential uses of
lematic if treatment is prolonged. Monitoring of cognition may be monitoring cognitive side-effects.
particularly important if maintenance treatment at a shorter inter-
val is unavoidable. Clinical planning
Regardless of the caveats above, some form of monitoring is clearly
Sine wave ECT desirable as it has the potential to guide treatment decisions. As dis-
Meta-analysis has shown that older machines that deliver ECT in cussed previously, choice of treatment modality depends on balan-
the form of a sine wave give rise to significantly greater cognitive cing clinical response and the potential for cognitive side-effects and
impairment than the brief or ultra-brief pulse machines that are this balance needs to be reviewed at regular intervals throughout a
now standard in most high-income countries.2,11 Of particular course of treatment and used to inform all aspects of the course
concern is data suggesting that ECT delivered using these machines of treatment. Clinical examples of this are given in Appendix 1.
resulted in impaired reaction time acutely and 6 months later.11 In An aspect of clinical planning that is important but sometimes
some parts of the world these machines are all that is available and neglected is the planning of recommendations in the weeks imme-
cannot be upgraded. However, their use may still be justified in diately following ECT. At this point recovery of new learning and
certain clinical situations. In this case, being aware of and monitor- executive function is variable and deficits may have an impact on
ing likely side-effects is particularly important. activities such as driving and work. Clinicians need to have some
understanding of cognitive functioning at this point in order to
advise on return to these sorts of activities.
Individual patient factors
Individual risk factors for cognitive side-effects Medicolegal issues
Baseline Modified Mini-Mental State Examination (3MS)23 scores Patients who believe they have developed significant cognitive impair-
correlate with autobiographical memory loss, such that those with ment following a course of ECT may take legal action. In this situation
lower scores have greater loss post-ECT.24 In addition, although systematic cognitive testing carried out before and after ECT may be
there is surprisingly little direct evidence, clinical experience sug- very useful in demonstrating the presence or absence of significant
gests that patients who are elderly, have pre-existing brain injury reduction in objectively measured cognitive function between pre-
or low intellectual ability are more vulnerable to the cognitive treatment and post-treatment and in demonstrating that the clinic
side-effects of ECT (see McClintock et al25 for a review). is active in anticipating and dealing with this problem.
Regarding severe loss of autobiographical memory, there is some
evidence that females are more vulnerable.11
Regarding medication concomitant with ECT, only lithium has How to monitor cognitive side-effects
been associated with significantly increased risk of cognitive side- Many clinics, even in high-income countries, will not have the
effects with ECT (see Loo et al26 for a review). Cognitive side- resources to conduct an extensive cognitive battery and until such
effects and delirium should be monitored more closely in patients intensive monitoring has been shown to be useful clinically,
administered lithium, particularly at higher serum levels.27,28 although not discouraging this, we do not recommend it as
routine. Therefore, testing must prioritise the most important
Monitoring cognitive side-effects issues and focus on these.
It would appear almost axiomatic that since cognitive side-effects
are distressing, and develop progressively over the course of treat- Candidate tests or domains for monitoring
ment, that they should be monitored in some way. Indeed, as Post-ictal disorientation. Patients may be disoriented for a variable
patients should be told that memory loss may occur and will period of time following an individual treatment. In the extreme

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Porter et al

case, this disorientation may persist in a fluctuating way for hours or over time in healthy participants.10 It is sensitive to differences in
days following a treatment – a post-ictal delirium. Sobin et al24 different methods of ECT, with the amount of information being
showed a correlation between time to orientation post-treatment forgotten at 6 months displaying a gradient from healthy partici-
and loss of autobiographical memory at 2 months after the end of pants at one end of the gradient to those having bilateral ECT at
the course. The correlation was driven by greater retrograde the other end, with unilateral ECT in between. The scale is,
amnesia in a small group of patients who had recovery of orienta- however, lengthy (281 questions over 1–3.5 h) making it impractical
tion more than 30 min after the treatment. With most modern for use in clinical practice.
treatments it is unusual for this to happen, but recording time to A shorter form was therefore developed (CUAMI- SF) that uti-
re-orientation and reporting to clinicians when this is greater lises only 30 questions, focusing on the previous 1 year. Areas
than, for example, 30 min is very simple and we recommend covered are shown in Appendix 2 and illustrate the areas in which
that this is done. More recently a small study confirmed the questioning has been able to elicit loss of memory. These items
predictive effect of re-orientation across both RUL and bilateral were chosen from the larger CUAMI because they produced high
ECT.32 A further and more rigorous development of this is the and equivalent rates of production of memories at baseline in
use of a specific questionnaire which, administered at 30 min patients with depression and controls, and because they differen-
post-ECT, in a small study correlated with loss of autobiographical tiated RUL from bilateral ECT. Both the CUAMI and its short
memory at the end of the course.33 Staff and families monitoring form have been criticised because they have not undergone the
patients between treatments should be aware of the symptoms of same rigorous standardisation as traditional neuropsychological
delirium. tests.39 However, they represent a specific attempt to perform a par-
ticular function, which is to measure loss of autobiographical
Global cognitive scales. Many units use scales measuring global memory, in research into ECT and, in the case of the CUAMI-SF,
cognitive performance as a means of monitoring. The 3MS has to attempt to produce a scale that can be used clinically to
been shown to be sensitive to differences short term (4–14 days) measure autobiographical memory loss during and after ECT. To
between 2 × weekly and 3 × weekly and between RUL and bilateral date, no better alternative has been developed.
electrode placement, and is able to detect the detrimental effects of Possible further criticisms may be that some of the items asked
ECT in the subacute period (0–4 days).2 On this basis, it is poten- are poorly discriminative in certain people or populations with dif-
tially useful for monitoring. Other similar scales may also be used ferent customs or lifestyles and that the test may not therefore build
on the same basis if they are more familiar to clinicians or more up a picture of important memories that are likely to be lost. For
available – for example the Montreal Cognitive Assessment34 or example, in our practice, questions about what the patient did at
the Addenbrooke’s Cognitive Examination. New Year do not elicit a lot of variable information in the elderly
people who have depression, who may easily be able to remember
Brief general cognitive batteries. Several previous papers have that they went to bed, as they do each year.
recommended shorter, more clinically practical batteries of cogni-
tive tests that could be delivered at intervals throughout a course.
Porter et al35 recommended a battery based on tests that had, in Subjective impairment. Although more complex questionnaires
research studies, shown significant differences between different assessing subjective memory tend to correlate better with mood
types of ECT (RUL versus bilateral) on the basis that these were than objective impairment, simpler questions regarding whether
therefore sensitive to aspects of ECT that could be modified if neces- ECT has ‘helped or hurt’ memory correlates well with objective
sary. Data on the utility of this battery in clinical practice are measurement of memory impairment.3,15 Therefore, this simple
awaited. An attempt has also been made to construct extremely question or a simple Likert scale may be very helpful in alerting clin-
short (few minutes) batteries of tasks, changes in which may be pre- icians to the onset of memory problems.
dictive of later cognitive difficulties.36 However, although correla- Individualising questions about autobiographical memory risks
tions between changes in this brief cognitive battery and tests of losing standardisation. This means that information regarding
anterograde memory post-ECT, there was no evidence that this whether a patient has reached a threshold of memory loss that is
was predictive of long-term loss of autobiographical memory. likely to become clinically concerning is not available. However,
Standardised, computerised batteries of cognitive tests may be a where resources are scarce, a practical alternative to the CUAMI-
method with future utility. SF is for clinicians to discuss with patients and their relatives
what they have experienced in the previous 1 year and elicit and
Anterograde amnesia. One of the most consistent findings, at record some details that the clinician can attempt to elicit again at
least in the short term, is impairment of new learning, shown by intervals during a course of ECT. This might involve relevant
reduced scores in verbal learning. This has often been demonstrated items from the CUAMI-SF and other items specific to the patient.
using the traditional Rey Verbal Learning Task37 or the shorter but Examples might include: have they attended a wedding? If so,
less sensitive Hopkins Verbal Learning Test.38 record details of who was getting married, who attended, where it
was held. Or have they attended a sporting event, and if so,
Retrograde amnesia. The planned nature of ECT allows an assess- who was playing. Suitable events could be suggested by family or
ment of stored memories, prior to the start of a course, in order to be friends.
able to monitor what has been lost. Usually, amnesia for autobio- Recent data suggests that although many patients have a sub-
graphic memory is measured. The most systematic approach to jective sense of memory problems following ECT, when patients
this is to elicit a large number of memories, record these and then perceptions of memory problems before the course of ECT are
prompt patients to retrieve the memories later in the course of treat- taken into account, a much lower percentage have a change in
ment. This has been done most commonly and systematically using this.40 Therefore it is helpful to ask about and record perceived
the CUAMI, a scale that was carefully constructed to illicit positive, memory gaps both before and after treatment.
negative and neutral memories and recent and remote events. The Family and friends are frequently asked about memory per-
same questions are then asked at intervals throughout a course of formance of patients receiving ECT but it is important to be specific
ECT to generate a score reflecting the amount of information for- about what is meant by ‘memory’ and what specific aspects are
gotten. This has been compared with the natural loss of memories being enquired about.

4
 Cognitive side‐effects of electroconvulsive therapy

High-risk situations It is noteworthy that although evidence suggests a return to

Some situations may be particularly high risk and merit increased baseline and even improvement within 14 days of the end of a
monitoring. Examples (but not an exhaustive list) include the course of ECT, patients may be attempting to return to their roles
following. in this period, something that could be hampered even by a brief
period of short-term cognitive dysfunction. Patients should be
(a) Patients who are likely to be at high risk – for example, elderly warned about this possibility and clinicians should attempt to
patients, those who have had significant brain injury or some gauge the extent of the problem. Even temporary impairment
other source of vulnerability such as concomitant lithium may set up a cycle of difficulty in functioning, negative appraisal
prescription. of performance and avoidance of cognitive activity, which in turn
(b) When the course of treatment extends beyond 12 treatments. may contribute to suboptimal recovery or to relapse.
This may not apply to UB-RUL which is relatively cognitive It is important to provide written information including to
sparing and more frequently requires a longer course for full family/support people as patients may not remember explanations
remission. later. Most professional bodies have written information and health
(c) Maintenance ECT, particularly if this has been at a frequency authorities usually have information sheets provided with consent
greater than monthly or is long term (longer than 1 year). sheets. These do not necessarily replace informed discussion.
Monitoring could be done at relatively infrequent intervals
(3 months to 1 year) making it more practical to undertake
repeated testing. Implications
(d) In low- and middle-income countries where it may not always
be possible to conduct ECT with the most up to date equipment ECT is a potentially life-saving treatment for severe MDEs and it is
(see ‘Sine wave ECT’ above). In this situation monitoring which frequently effective in cases of treatment-resistant MDEs. The main
can be quickly undertaken by relatively unskilled personnel, disadvantage is that it is associated with cognitive side-effects.
according to the suggestions in Appendix 3, may be possible Some forms of ECT minimise the risk of these side-effects but in
and guide treatment decisions. some patients this is at the expense of reduced efficacy. Despite con-
siderable advances in technique there is still the need to strike a
careful balance between efficacy and side-effects. The most important
Discussion area of cognitive effects associated with ECT is loss of autobio-
graphical memory, which is distressing for some patients, and all
What should we tell patients? patients should be informed of the possible nature and extent of
The following list is a distillation of our understanding of the cogni- this phenomenon. Data suggesting a lack of effect on other aspects
tive side-effects of ECT, which we believe incorporates the most of cognition is based on group means and does not exclude the pos-
important points that should be conveyed to patients and their fam- sibility that a subgroup of patients experience deficits that are masked
ilies regarding this issue. by a general improvement in cognition in the rest of the group.
Monitoring is demanding and research findings regarding the
(a) ECT may cause loss of memory for things that patients have best way of monitoring is limited, but some basic monitoring can
learnt or experienced. Some patients find this distressing but be achieved relatively easily. It is important to give very clear infor-
some do not. mation to patients and their families.
(b) This memory loss is normally worse for the time immediately
before ECT (3 months) – but sometimes extends back for up to
Richard J. Porter , Treatment Algorithm Group; and Department of Psychological
1 year and may occasionally extend beyond this. Medicine, University of Otago – Christchurch, New Zealand; Bernhard T. Baune,
(c) Usually this memory loss will improve significantly by 6 Treatment Algorithm Group; and Department of Psychiatry, University of Melbourne,
months but depression may result in residual problems and Australia; Grace Morris , Treatment Algorithm Group; Academic Department of
Psychiatry, Northern Sydney Local Health District; Sydney Medical School Northern,
some of the memories for things that have been experienced University of Sydney; and CADE Clinic, Royal North Shore Hospital, Northern Sydney Local
will not return. Health District, Australia; Amber Hamilton, Treatment Algorithm Group; Academic
Department of Psychiatry, Northern Sydney Local Health District; Sydney Medical School
(d) Ability to learn new ‘things’ will be less for a short time after Northern, University of Sydney; and CADE Clinic, Royal North Shore Hospital, Northern
ECT – this is usually for a maximum of 2 weeks, at which Sydney Local Health District, Australia; Darryl Bassett, Treatment Algorithm Group; and
Private Practice in Psychiatry and Division of Psychiatry, the University of Western
point, this ability will be back to baseline. This may delay Australia, Australia; Philip Boyce, Treatment Algorithm Group; and Discipline of
return to usual activities. Psychiatry, Sydney Medical School, Westmead Clinical School, University of Sydney,
Australia; Malcolm J. Hopwood, Treatment Algorithm Group; and Department of
(e) Ability to plan things, concentrate and attend to things may be Psychiatry, University of Melbourne, Australia; Roger Mulder, Treatment Algorithm
improved because the depression has been treated. Group; and Department of Psychological Medicine, University of Otago – Christchurch,
New Zealand; Gordon Parker, Treatment Algorithm Group; School of Psychiatry,
(f) Beyond possible effects of ECT on learning and memory, University of New South Wales; and Black Dog Institute, Australia; Ajeet B. Singh,
unfortunately severe depression itself is related to problems Treatment Algorithm Group; and School of Medicine, IMPACT Strategic Research Centre,
Deakin University, Australia; Tim Outhred, Treatment Algorithm Group; Academic
with learning and memory and for some people this does not Department of Psychiatry, Northern Sydney Local Health District; Sydney Medical School
improve completely even when the depression has consider- Northern, University of Sydney; and CADE Clinic, Royal North Shore Hospital, Northern
Sydney Local Health District, Australia; Pritha Das, Treatment Algorithm Group;
ably improved. Academic Department of Psychiatry, Northern Sydney Local Health District; Sydney
Medical School Northern, University of Sydney; and CADE Clinic, Royal North Shore
Each aspect of these side-effects should be emphasised more for Hospital, Northern Sydney Local Health District, Australia; Gin S. Malhi , Treatment
patients whose ECT treatment parameters or risk factors make the Algorithm Group; Academic Department of Psychiatry, Northern Sydney Local Health
District; Sydney Medical School Northern, University of Sydney; and CADE Clinic, Royal
problems more likely: North Shore Hospital, Northern Sydney Local Health District, Australia

(a) bilateral (bitemporal/bifrontal) ECT; Correspondence: Gin S. Malhi. Email: [email protected]

(b) prolonged course of standard treatment or frequent mainten- First received 28 Aug 2019, final revision 26 Feb 2020, accepted 3 Mar 2020
ance treatment;
(c) existing cognitive difficulties (brain injury, intellectual disabil-
Data availability
ity, other existing brain disease);
(d) elderly patients. Data sharing is not applicable to this article as no new data were created or analysed in this
study.

5
Porter et al

(c) Probes each area with five further questions – for example,
Author contributions
travel (number of days away, name of lodging, travel compa-
R.J.P., B.T.B., G.M., A.H., D.B., P.B., M.J.H., R.M., G.P., A.B.S. and G.S.M. were involved in devel- nions, reason for trip and what was enjoyed about the trip).
oping the main conceptual ideas and planning of the manuscript. R.J.P. conducted the majority
of the literature review and drafted the manuscript with input from authors. All authors (d) Subsequent scores based on information given at baseline and
reviewed and approved the final version of the manuscript. can be expressed as percentage lost.
(e) Takes 10–20 min to administer.
Funding
National Health and Medical Research Council, Grant/Award Number: 1037196. The Treatment
Algorithm Group (TAG) was supported logistically by Servier who provided financial assistance
with travel and accommodation for those TAG members travelling interstate or overseas to Appendix 3
attend the meeting in Sydney (held on 18 November 2017). None of the committee were
paid to participate in this project and Servier have not had any input into the content, format
or outputs from this project.
Recommendations for monitoring of cognitive function
Declaration of interest during and after electroconvulsive therapy
R.J.P. uses software for research at no cost from Scientific Brain Training Pro and support for
Minimal screening
travel and accommodation from Servier and Lundbeck, outside the submitted work. P.B. (a) Record and report any failure to be oriented more than 30 min
reports personal fees from Servier, personal fees from Lundbeck and personal fees from
Douglas Pharmaceuticals, outside the submitted work. M.J.H. has received grants and personal
after a treatment.
fees from Servier and personal fees from Janssen-Cilag, Lundbeck, Eli Lilly, Hahn, Sequiris, (b) Educate all carers regarding features of inter-ictal delirium.
Bionomics and Mundipharma, outside the submitted work. G.P. has spoken at meetings or
been on advisory boards for the following companies: Servier, Lundbeck and Otsuka, outside
(c) Enquire at baseline about important events in the patient’s life
the submitted work. A.B.S. has been a speaker for Servier, Lundbeck and Otsuka and has equity during the previous 1 year. Elicit and record some salient
in CNSDose LLC and ABC Life Pty Ltd, outside the submitted work. G.S.M. has received grant or details. Discuss with family/support people and confirm. Ask
research support from AstraZeneca, Eli Lilly, Organon, Pfizer, Servier and Wyeth; has been a
speaker for AstraZeneca, Eli Lilly, Janessen-Cilag, Lundbeck, Pfizer, Ranbaxy, Servier and about these events regularly (every three treatments). Record
Wyeth; and has been a consultant for AstraZeneca, EliLilly, Janssen-Cilag, Lundbeck and whether there is a significant loss of memory for these events.
Servier, outside the submitted work.
ICMJE forms are in the supplementary material, available online at https://doi.org/10.1192/bjo. (d) Enquire of patient and relatives (and nursing staff if the patient
2020.17. is an in-patient) regarding any evidence of memory loss both
prior to and after treatment. Explain to all three groups what
autobiographical memory is and the types of memory that
may therefore be lost.
Appendix 1 (e) Ask patients whether they believe the treatment has ‘helped’ or
‘hurt’ their memory and consider rating on a scale of one to
seven, with four being neutral.
Clinical examples of monitoring in practice
Example one If resources exist
A 78-year-old with moderate depression and treatment resistance (a) Consider doing the Modified Mini-Mental State Examination
shows minimal response after six treatments with ultra-brief right or similar brief cognitive screen
unilateral (RUL) electroconvulsive therapy (ECT) despite increases (b) Consider undertaking a formal Columbia University
in dose. Cognitive monitoring suggests no deterioration. Therefore, Autobiographical Interview – Short Form.
a decision is made to change to brief pulse RUL. (c) Consider doing a test of anterograde memory for example
(Hopkins Verbal Learning Test30 or Rey Verbal Learning Test29).
Example two Frequency
A 40-year-old with severe, suicidal and psychotic depression shows (a) Baseline and after every two to three treatments.
significant improvement but still presents with moderate symptoms (b) More frequently in high-risk situations.
after six treatments with bilateral ECT. Cognitive monitoring shows (c) Three to four days after the last treatment of the course of elec-
a very significant loss of autobiographical memory. In this situation troconvulsive therapy to guide planning of return to activities.
the decision was made to switch to RUL ECT until full remission
was achieved.
References
Example three
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