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Cognitive Impairment Not a Contraindication to ECT in Older Adults

Key findings

  • This study explored changes in cognition and depression in 684 patients, age 50 or older, with and without baseline cognitive impairment who underwent electroconvulsive therapy (ECT)
  • Normal cognition at baseline was associated with cognitive decline after 10 ECT treatments (-1.44 points on the MoCA) whereas baseline cognitive impairment was associated with improved cognitive functioning of similar magnitude (+1.72 points)
  • Baseline cognitive status was not associated with differential improvement on the Quick Inventory of Depressive Symptomatology
  • Mildly to moderately impaired cognitive function need not be considered a contraindication to ECT in adults 50 and older

Electroconvulsive therapy (ECT) is established to be efficacious across the age span, but concerns about cognitive effects sometimes limit its acceptance. Patients already experiencing cognitive impairment may be particularly averse.

Michael E. Henry, MD, director of electroconvulsive therapy and medical director of the Dauten Family Center for Bipolar Treatment Innovation at Massachusetts General Hospital, James Luccarelli, MD, DPhil, a resident in the Department of Psychiatry, and colleagues concluded from a retrospective study that patients with impaired global cognitive function at baseline did not have worsening of cognition after ECT. Their data appeared in The American Journal of Geriatric Psychiatry.


The study included 684 patients who were at least 50 years old (mean age 62) who received acute-course ECT between May 2011 and June 2019 at a freestanding psychiatric hospital. 77% of patients had major depressive disorder, 20% had bipolar disorder, and 2% had schizoaffective disorder.

The vast majority of patients were treated with a cognition-sparing protocol: 97% had right unilateral electrode placement and 92% received ultra-brief pulse stimuli.

As part of routine care, patients completed the Montreal Cognitive Assessment (MoCA) at baseline and immediately before the eleventh treatment. They reported depression symptoms using the 16-item Quick Inventory of Depressive Symptomatology (QIDS).

Change in Cognition

At baseline, the mean MoCA score was 25.3. The distribution of scores was:

  • >25 (normal cognition)—54.2%
  • 18–25 (mild impairment)—43.4%
  • 10–17 (moderate impairment)—2.3%
  • <10 (severe impairment)—0%

After 10 ECT treatments, the mean MoCA score was unchanged (25.2; P=0.86). According to cognitive status at baseline, the average change was:

  • A 1.44-point decrease in patients with normal cognition
  • A 1.72-point increase in patients with cognitive impairment

Change in Depressive Symptoms

At baseline the mean QIDS score was 17.0, indicating severe depressive symptoms. Baseline cognitive status was not significantly associated with a change in QIDS (−0.84 point for patients with normal baseline cognition compared with those who had impaired cognitive function at baseline; P=0.064).

In light of these findings, mildly to moderately impaired cognitive function is not a contraindication to ECT in adults 50 and older.

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