Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2018 Feb 1.
Published in final edited form as: J Affect Disord. 2016 Nov 11;209:39–45. doi: 10.1016/j.jad.2016.11.003

Effects of a right unilateral ultrabrief pulse electroconvulsive therapy course on health related quality of life in elderly depressed patients☆

W Vaughn McCall a,b,c,d,e,f,g,h,i,*, Sarah H Lisanby a,b,c,d,e,f,g,h,i, Peter B Rosenquist a,b,c,d,e,f,g,h,i, Mary Dooley a,b,c,d,e,f,g,h,i, Mustafa M Husain a,b,c,d,e,f,g,h,i, Rebecca G Knapp a,b,c,d,e,f,g,h,i, Georgios Petrides a,b,c,d,e,f,g,h,i, Matthew V Rudorfer a,b,c,d,e,f,g,h,i, Robert C Young a,b,c,d,e,f,g,h,i, Shawn M McClintock a,b,c,d,e,f,g,h,i, Martina Mueller a,b,c,d,e,f,g,h,i, Joan Prudic a,b,c,d,e,f,g,h,i, Robert M Greenberg a,b,c,d,e,f,g,h,i, Richard D Weiner a,b,c,d,e,f,g,h,i, Samuel H Bailine a,b,c,d,e,f,g,h,i, Mary Anne Riley a,b,c,d,e,f,g,h,i, Laryssa McCloud a,b,c,d,e,f,g,h,i, Charles H Kellner a,b,c,d,e,f,g,h,i; the CORE/PRIDE Work Groupa,b,c,d,e,f,g,h,i
PMCID: PMC5278419  NIHMSID: NIHMS831886  PMID: 27886569

Abstract

Introduction

Patients with Major Depressive Disorder (MDD) referred for electroconvulsive therapy (ECT) have poorer Health Related Quality of Life (HRQOL), compared with other patients with MDD, but ECT is associated with significant and durable improvement in HRQOL. However, no prior research has focused exclusively on elderly patients with MDD receiving ECT.

Methods

HRQOL data from 240 depressed patients over the age of 60 was measured with the Medical Outcomes Study Short Form 36 (SF-36). The SF-36 was measured before and after a course of acute ECT. Predictors of change in HRQOL scores were identified by generalized linear modeling.

Results

At baseline, participants showed very poor HRQOL. After treatment with ECT, the full sample showed marked and significant improvement across all SF-36 measures, with the largest gains seen in dimensions of mental health. Across all participants, the Physical Component Summary (PCS) score improved by 2.1 standardized points (95% CI, 0.61,3.56), while the Mental Component Summary (MCS) score improved by 12.5 points (95% CI, 7.2,10.8) Compared with non-remitters, remitters showed a trend toward greater improvement in the PCS summary score of 2.7 points (95%CI, −0.45, 5.9), while the improvement in the MCS summary score was significantly greater (8.5 points, 95% CI, 4.6,12.3) in the remitters than non-remitters. Post-ECT SF-36 measurements were consistently and positively related to baseline scores and remitter/non-remitter status or change in depression severity from baseline. Objective measures of cognitive function had no significant relationships to changes in SF-36 scores.

Limitations

This study’s limitations include that it was an open label study with no comparison group, and generalizability is limited to elderly patients.

Discussion

ECT providers and elderly patients with MDD treated with ECT can be confident that ECT will result in improved HRQOL in the short-term. Attaining remission is a key factor in the improvement of HRQOL. Acute changes in select cognitive functions were outweighed by improvement in depressive symptoms in determining the short term HRQOL of the participants treated with ECT.

Keywords: ECT, quality of life, major depressive disorder, elderly

Introduction

While world-wide progress is being made in reducing the mortality due to common infectious diseases and dietary deficiency,(Lozano et al., 2012) there is little evidence of progress in reducing the morbidity due to mental illness. The World Health Organization has predicted that major depressive disorder (MDD) will become a leading cause of world-wide disability. (WHO Guidelines Approved by the Guidelines Review Committee, 2011) The relationship of MDD to disability is dependent upon the age of the patient.(McCall et al., 1999a) Young patients with MDD are more likely to report problems with relationships, while older patients with MDD are more likely to report problems with managing the demands of everyday life. For the purposes of this paper, we will use the term ‘function’ to describe observable behaviors such as activities of daily living (ADLs) and instrumental activities of daily living (IADLs), while the term ‘health-related quality of life’ (HRQOL) is reserved to describe self-reports of health dimensions (e.g., pain, fatigue, competence in performing an emotional role). Patients are generally able to accurately describe their level of functional activity, even after a course of electroconvulsive therapy (ECT). (McCall et al., 2002)

Patients with MDD who are referred for ECT have poorer scores on measures of HRQOL relative to unselected outpatients with MDD.(McCall et al., 2013) Naturalistic observation of a mixed-age sample of 88 inpatients with MDD who received ECT showed greater improvement in HRQOL as measured by the Daily Living and Role Functioning of the Basis-32, with an effect size advantage >1.0 at one month after hospitalization, as compared with inpatients with MDD who did not receive ECT.(McCall et al., 2001) Antunes and Fleck reported on the change in HRQOL using the Basis −32 and the World Health Organization Quality of Life scale, and reported a large effect size improvement of approximately 1.0.(Antunes et al., 2009) In a mixed-age sample of 77 patients with MDD (mean age 57.3 years), impairments in HRQOL were improved by a factor of about 50% 2 weeks and 4 weeks after an ECT course. Improvement in HRQOL was explained by reduction in depression symptom severity, while improvement in IADLs was related to improved cognitive function after ECT.(McCall et al., 2004) In another study, 184 mixed-aged adults (mean age 47.6) received a course of bilateral (BL) or right unilateral (RUL) ECT to treat MDD, and were followed for 6 months. HRQOL was exceptionally poor before ECT, and improved immediately after the ECT course. Remission from MDD was associated with greater gains in HRQOL than non-remission. Interestingly, continued gains in HRQOL over 6 months was related to both sustained remission over 6-months and to electrode placement, as participants assigned to RUL relative to BL electrode placement had better HRQOL outcomes. In this study, HRQOL was unrelated to changes in cognitive function.(McCall WV et al., 2011) The ECT Services study included 283 mixed-age participants with MDD (mean age 55.4 years) treated with ECT according to provider preference and HRQOL was measured with the Medical Outcomes Study Short Form 36 (SF-36). In this study, improvement was seen widespread, with 87% of participants showing improved scores, with remitters showing approximately an effect size of 1.0, and non-remitters had an improvement effect size of approximately 0.5. The gains were sustained for up to 6 months, with those participants showing the greatest improvement in measures of global cognitive function also showing the greatest improvement in HRQOL.(McCall et al., 2006) Increasing age in this study was associated with greater improvement in the HRQOL domains of mental health and social function, but less improvement in the physical function domain.

While the accumulated evidence suggests that patients with MDD treated with ECT have poorer baseline HRQOL, compared with other patients with MDD, and that they experience significant improvement in HRQOL that persists for months after ECT, no prior research has focused exclusively on elderly adult patients with MDD receiving ECT. Specific examination of the effects of ECT on elderly patients with MDD would be valuable for several reasons: (1) elderly patients with MDD are disproportionally represented among patients with MDD treated with ECT,(McCall et al., 1999b) (2) concerns about pre-ECT and post-ECT cognitive status of elderly patients with MDD raises questions about the impact of ECT on HRQOL,(McCall et al., 2003) (3) as elderly patients with MDD treated with ECT have better antidepressant response to ECT than younger patients, it raises the possibility of an enhanced effect on HRQOL,(Rhebergen et al., 2015;Tew et al., 1999) and (4) the differential impact of depression on IADLs and HRQOL in depressed elderly relative to younger patients with MDD.(McCall, Cohen, Reboussin, and Lawton, 1999a) To address this knowledge gap, we undertook a secondary analysis of the “Prolonging Remission in Depressed Elderly” (PRIDE) study data acquired in Phase 1 in which elderly adults with MDD were treated with a combination of right unilateral ultra-brief pulse ECT and venlafaxine.

Methods

Patients

Full details of the methods of Phase 1 of the PRIDE study can be found elsewhere.(Kellner et al., 2016) Recruitment occurred at multiple sites, and approval for the study was obtained from the institutional review board (IRB) at each study site. Participants provided their own, written, informed consent. Briefly, participants were in- or outpatients, age ≥60, with a diagnosis of unipolar MDD, and a Hamilton Rating Scale for Depression-24 item (HRSD24) total score ≥21. (Hamilton, 1960) All participants received venlafaxine (VLF) during both the acute ECT course and during continuation therapy after acute ECT, while all participants who proceed from the acute ECT course to the randomized second phase of treatment (not considered in this paper) received lithium (Li). Hence, all participants had to be candidates to receive both VLF and Li in Phase 1. Exclusion criteria were bipolar disorder, schizoaffective disorder, dementia, substance abuse/dependence in last 6 months, contraindications to Li or VLF, or prior failure to respond to an adequate trial of Li + VLF in the index episode, or any ECT in the current episode. Also participants with a history of active general medical or neurological conditions that would have affected cognition or treatment response, such as Parkinson’s Disease, stroke, or multiple sclerosis, were excluded. The participants’ severity of general medical conditions was measured with the Cumulative Illness Rating Scale – geriatric (CIRS-G).(Linn et al., 1986)

Procedures

Medication Washout and Concomitant Medications

Psychotropic medications were discontinued within 1 week of starting Phase 1, except for venlafaxine as described below. Rescue medication for agitation, anxiety, or insomnia was limited to lorazepam up to 3 mg/day, or equivalent.

ECT

ECT procedures were standardized as follows: 3x weekly, standard RUL placement (D’Elia placement)(D’Elia et al., 1975) with ultrabrief (UB) pulse (≤ 0.3 ms) stimuli. A dose titration procedure to determine seizure threshold was carried out at the initial session, and subsequent sessions were administered at 6x seizure threshold. Seizure adequacy criterion was a motor seizure ≥ 15 s, with restimulation, if needed. If the HRSD24 demonstrated <25% drop from baseline by treatment 6, the stimulus dose was increased by 50%. If the HRSD24 demonstrated <25% drop from baseline by treatment 9, the stimulus dose was increased again by 50%.

Medication

VLF was started 1–5 days prior to ECT or up to 2 days after the first treatment at an initial dosage of 37.5 mg po, increased by 37.5 mg every 3 days or as tolerated, with a target dose of 225 mg qD.

Assessments

Diagnostic, Demographic and Baseline Clinical Assessments

Baseline assessments were obtained for eligible participants who provided informed consent. Diagnosis was established using either the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I)(Spitzer et al., 1992) (study years 1–2) or the Mini-International Neuropsychiatric Interview (MINI)(Sheehan et al., 1998) (years 3–6). The change to the MINI as a diagnostic instrument was made to minimize patient burden at the baseline assessment. As the SCID-I and the MINI have similar diagnostic accuracy (Sheehan et al., 1997; Sheehan et al., 1998; Kotwicki & Harvey, 2013),(Kotwicki et al., 2013;Sheehan et al., 1997;Sheehan, Lecrubier, Harnett-Sheehan, Amorim, Janavs, Weiller, Hergueta, Baker, and Dunbar, 1998) we did not account for the change in diagnostic tool in the statistical analysis. The change from the SCID to the MINI at year 3 was approved by the Data Safety and Monitoring Board (DSMB).

These instruments were further used to specify the melancholic, atypical, and psychotic subtypes of Major Depressive Disorder.

Depression outcome measures

The HRSD24 was administered three times per week, before each ECT. The primary outcomes in Phase 1 were remission status and the longitudinal trajectory of HRSD24 total scores. Participants were classified as remitters based on: (a) HRSD24 ≤10 on two consecutive ratings, and (b) HRSD24 did not increase > 3 points on the second consecutive HRSD24, or remained ≥ 6, consistent with other ECT clinical trials in MDD.(Sackeim et al., 2009) The minimum number of ECT required for remission was 2, but there was no maximum. Non-remitters: (a) did not meet the above remission criteria, (b) had at least 12 treatments, and (c) reached a plateau defined as no clinical improvement (< 3 point decrease in HRSD24 after last 2 consecutive treatments).

Cognitive Function

The Wechsler Test of Adult Reading (WTAR) was administered only at baseline as an estimate of pre-morbid intellectual functioning.(Wechsler, 2001) Global cognitive function was measured with the Mini Mental State Examination (MMSE).(Folstein et al., 1975) The second edition of the California Verbal Learning Test (CVLT-II) was used to assess verbal learning and memory.(Delis et al., 2000;Woods et al., 2006) The Dementia Rating Scale 2nd edition Initiation/Perseveration Index (DRS-2 I/P) was used to measure executive function.(Lezak et al., 2004)

HRQOL

HRQOL was measured with the Medical Outcomes Study Short Form 36 (SF-36).(Ware, Jr. et al., 1992;Ware et al., 2003) The SF-36 was measured at baseline prior to ECT, and again at the end of Phase 1 acute ECT. SF-36 data were scored in terms of 8 standard subscales: Physical Functioning (PF), Role Physical (RP), Bodily Pain (BP), General Health (GH), Vitality (VT), Social Functioning (SF), Role Emotional (RE), and Mental Health (MH). The score for each subscale is the weighted sums of the questions for that subscale, transformed into a 0–100 scale. Lower scores define greater disability. Individual scores were then transformed into “T scores” (i.e., standardized scores), with a mean of 50 and standard deviation of 10. The 8 subscales were also aggregated into two total scores – the Physical Component Summary T score (PCS) and the Mental Component Summary T score (MCS). Both total scores were obtained summing over all eight subscales scores weighed by their respective physical and mental factor score coefficient following the algorithm provided by Ware, Kosinski & Dewey)(Ware et al., 2000).

Statistical Analysis

For continuous and categorical group comparisons, independent sample t-tests and chi-square tests were used respectively. All analyses were conducted using SAS 9.4.

Multiple imputation was used to handle missing data. Missingness was assessed at baseline and post assessment measurement for putative predictors; each missing baseline and post assessment measurement SF-36 subscale and summary score was imputed 100 times using SAS Proc MI with the Markov Chain Monte Carlo (MCMC) method. Following imputation, standard statistical methods were used and results were combined across imputations using SAS Proc MIAnalyze which accounts for the variability between imputed values in the 100 datasets. Models were assessed using available standard methods such as imputation model residuals to confirm Gaussian distribution assumptions are met and autocorrelation plots to verify that imputation converged. Each imputation model for the individual subscale and summary scores included remission status, study site, age, gender, psychosis, education, CIRSG severity, WTAR baseline Full Scale IQ, MMSE baseline raw score, HRSD24 baseline and post assessment total score, CVLT-II delayed recall and percent retention scores, and DRS-2 I/P scaled score. For calculation of CIRSG severity score the rating of psychiatric impairment was excluded due the otential for multicollinearity with other measures including HRSD24.

To evaluate significant change from baseline to post assessment for the total sample for each SF-36 subscale and summary score for the imputed data set, paired t-tests were used to test the difference from zero for the total sample. Pooled t-tests were used to compare the difference in mean change from baseline between remitters and non-remitters.

To evaluate the predictors of change from baseline in quality of life subscale and summary scores, generalized linear models (GLM) were used. Post assessment SF-36 subscale and summary scores were used separately as the outcome measure (dependent variable); all models contained baseline SF-36 subscale or summary score, baseline premorbid intellectual ability (WTAR), change from baseline in MMSE, delayed recall and percent retention (CVLT-II), and the DRS-2 I/P. Furthermore, remission status was included for subscale and summary scores related to mental health and change in the HRSD24 total score was included for subscale and summary scores related to physical functioning. In addition, potential covariates (age, gender, psychosis, education, and CIRSG severity) were assessed for significance in bivariate models and included in the full model if the p-value was <0.20. The full model was assessed and the covariate with the highest p-value was subsequently removed and the model rerun. This was repeated until only statistically significant covariates remained.

Results

Two-hundred and forty patients contributed to the analyses. The sample was mostly female and White, with severe depressive symptoms and intact global cognitive function at baseline (Table 1). Baseline demographic and clinical features were similar between remitters and non-remitters with remission status determined based on the post HRSD24 score. At baseline, participants showed very poor HRQOL on each subscale and the 2 summary scores, with the exception of the PCS and the BP subscale that approached a normative mean value of 50 (Table 2). The HRSD baseline for patients diagnosed with SCID versus MINI were very similar, (MINI: 31.6 +/− 7.4 vs SCIID: 30.3 +/− 7.1; difference: −1.2+/−7.3; p=0.258) supporting the idea that SCID and MINI are equivalent in detecting major depressive disorder.

Table 1.

Demographic and clinical characteristics at baseline for total sample and by remitter status

Characteristic Total Sample Non-remitter Remitter p-value
N n n
DEMOGRAPHICS
 Age (y) 240 69.9 ± 7.6 (68.5) 92 68.8 ± 7.8 (66.5) 148 70.6 ± 7.3 (70.0) 0.077
 Education (y) 239 14.5 ± 3.3 (14.0) 91 14.5 ± 3.3 (14.0) 148 14.5 ± 3.3 (14.0) 0.998
 Female 240 46 (57.5%) 92 46 (50.0%) 148 92 (62.2%) 0.064
 White 240 228 (95.0%) 92 87 (94.6%) 148 141 (95.3%) 0.807
 Hispanic 240 9 (3.8%) 92 3 (3.3%) 148 6 (4.1%) -
BASELINE CLINICAL CHARACTERISTICS
 Recurrent Episode 240 210 (87.5%) 92 82 (89.1%) 148 128 (86.5%) 0.547
 Psychosis 240 28 (11.7%) 92 8 (8.7%) 148 20 (13.5%) 0.258
 Melancholia 239 141 (59.0%) 91 58 (63.7%) 148 83 (56.1%) 0.243
 Atypical 239 5 (2.1%) 91 1 (1.1%) 148 4 (2.7%) -
 Psychiatric Hospitalizations 229 2.4 ± 3.4 (2.0) 86 2.7 ± 4.9 (1.0) 143 2.2 ± 2.0 (2.0) 0.367
 HRSD24 Baseline 240 31.2 ± 7.3 (30.0) 92 31.8 ± 7.1 (31.0) 148 30.9 ± 7.4 (30.0) 0.320
 MMSE Baseline (raw) 239 27.5 ± 2.4 (28.0) 91 27.5 ± 2.6 (28.0) 148 27.5 ± 2.2 (28.0) 0.803
 CIRS-G Severity Index1 223 1.5 ± 0.4 (1.5) 88 1.5 ± 0.4 (1.5) 135 1.4 ± 0.4 (1.4) 0.292
 WTAR IQ Score 208 106.0 ± 10.2 (108.0) 74 105.9 ± 9.9 (108.0) 134 106.1 ± 10.5 (108.0) 0.928
 DRS-2 I/P AMSS Score 222 8.0 ± 3.2 (8.0) 81 8.4 ± 2.9 (10.0) 141 7.8 ± 3.3 (8.0) 0.141
DEMOGRAPHICS
 CVLT % Retention 200 68.9 ± 35.9 (75.0) 73 69.8 ± 36.1 (75.0) 127 68.0 ± 35.8 (80.0) 0.735
 CVLT Long delay free recall standard score 203 −1.0 ± 1.2 (−1.0) 73 −0.9 ± 1.3 (−1.0) 130 −1.0 ± 1.2 (−1.0) 0.559
FAMILY HISTORY OF MENTAL DISORDERS
 Psychiatric Illness 233 160 (68.7%) 89 60 (67.4%) 144 100 (69.4%) 0.746
 Mood Disorder 231 143 (61.9%) 88 56 (63.6%) 143 87 (60.8%) 0.671
 Major Depressive Disorder 230 136 (59.1%) 88 55 (62.5%) 142 81 (57.0%) 0.413
 Bipolar Disorder 231 33 (14.3%) 88 12 (13.6%) 143 21 (14.7%) 0.825
Open in a new tab

Data are represented as mean ± SD (median) for continuous variables and number (%) for categorical.

1

Psychiatric item removed

Table 2.

Mean difference from baseline in SF-36 subscale and summary T scores for total sample

TOTAL SAMPLE
SF-36 T scores Baseline Mean (SE) Last Mean (SE) Difference1 Mean (95% CI) P-Value
Physical Factors
 Physical Component Summary (PCS) 45.76 (.81) 47.84 (.75) 2.09 (0.61, 3.56) 0.0058
 Bodily Pain (BP) 44.68 (.89) 47.71 (.84) 3.03 (1.24, 4.82) 0.0009
 Role Physical (RP) 32.97 (.83) 39.05 (.84) 6.07 (4.24, 7.90) <0.0001
 General Health (GH) 39.61 (.74) 45.65 (.70) 6.04 (4.55, 7.53) <0.0001
 Physical Functioning (PF) 37.28 (.82) 41.33 (.80) 4.05 (2.43, 5.67) <0.0001
Mental Factors
 Mental Component Summary (MCS) 18.30 (.69) 30.79 (.93) 12.49 (10.61, 14.38) <0.0001
 Mental Health (MH) 21.55 (.67) 34.48 (.81) 12.93 (11.21, 14.65) <0.0001
 Role Emotional (RE) 21.38 (.68) 29.84 (.89) 8.46 (6.38, 10.54) <0.0001
 Vitality (VT) 31.67 (.64) 41.26 (.75) 9.59 (7.88, 11.30) <0.0001
 Social Functioning (SF) 24.05 (.67) 33.05 (.84) 9.00 (7.18, 10.82) <0.0001
Open in a new tab
1

Difference = Post minus Baseline score

Participants received a mean of 7.4 + 3.5 ECT sessions (median: 7; range: 1–16). At the conclusion of ECT, the full sample showed marked and significant improvement across all SF-36 subscales and summary scores, with the biggest gains seen in dimensions of mental health (Table 2). Compared with non-remitters, remitters showed greater improvement in SF-36 scores pertaining to dimensions of mental health. No HRQOL subscales declined after ECT in either the remitter or the non-remitter groups (Table 3).

Table 3.

Mean Baseline, Post, and Difference from baseline in SF-36 subscale and summary T-scores by outcome status.

SF-36 T-scores Remitter
 Mean (SE)		 Non-remitter
 Mean (SE)		 Difference (Remitter minus Non-Remitter)
 Mean (95% CI)		 p-value
Physical Component Summary (PCS)
 Baseline 45.9 (0.95) 45.5 (1.49) 0.42 (−2.94, 3.78) 0.8083
 Post 49.1 (0.85) 45.9 (1.38) 3.15 (0.00, 6.30) 0.0497
 Difference (Post-Baseline) 3.13 (1.51, 4.75) 0.40 (−2.42, 3.22) 2.73 (−0.45, 5.91) 0.0919
 p-value 0.0002 0.7806
Bodily Pain (BP)
 Baseline 45.0 (1.07) 44.1 (1.55) 0.93 (−2.72, 4.57) 0.6182
 Post 48.8 (0.94) 46.0 (1.59) 2.83 (−0.73, 6.39) 0.1188
 Difference (Post-Baseline) 3.76 (1.74, 5.78) 1.86 (−1.43, 5.14) 1.91 (−1.88, 5.70) 0.3236
 p-value 0.0003 0.2683
Role Physical (RP)
 Baseline 32.5 (1.00) 33.8 (1.45) −1.30 (−4.69, 2.10) 0.4539
 Post 41.0 (0.92) 35.9 (1.57) 5.16 (1.66, 8.67) 0.0039
 Difference (Post-Baseline) 8.55 (6.51, 10.59) 2.09 (−1.17, 5.35) 6.46 (2.68, 10.24) 0.0008
 p-value <.0001 0.2088
General Health (GH)
 Baseline 40.6 (0.91) 38.1 (1.25) 2.47 (−0.55, 5.49) 0.1085
 Post 49.4 (0.68) 39.6 (1.24) 9.80 (7.15, 12.45) <.0001
 Difference (Post-Baseline) 8.85 (−10.58, − 7.28) 1.52 (−4.09, 1.23) 7.33 (4.30, 10.35) <.0001
 p-value <.0001 0.2551
Physical Functioning (PF)
 Baseline 37.8 (0.99) 36.4 (1.42) 1.47 (−1.88, 4.81) 0.3896
 Post 42.9 (0.93) 38.8 (1.43) 4.07 (0.73, 7.40) 0.0170
 Difference (Post-Baseline) 5.05 (3.20, 6.89) 2.45 (−0.53, 5.42) 2.60 (−0.85, 6.05) 0.1395
 p-value <.0001 0.1067
Mental Component Summary (MCS)
 Baseline 19.2 (0.87) 16.9 (1.13) 2.27 (−0.54, 5.08) 0.1128
 Post 34.9 (0.98) 24.2 (1.62) 10.73 (7.07, 14.39) <.0001
 Difference (Post-Baseline) 15.74 (13.72, 17.76) 7.28 (3.88, 10.68) 8.46 (4.58, 12.34) <.0001
 p-value <.0001 <.0001
Mental Health (MH)
 Baseline 22.6 (0.86) 19.9 (1.03) 2.70 (−0.01, 5.41) 0.0508
 Post 38.4 (0.81) 28.2 (1.44) 10.1 (6.97, 13.27) <.0001
 Difference (Post-Baseline) 15.78 (13.82, 17.73) 8.35 (5.40, 11.31) 7.42 (3.88, 10.96) <.0001
 p-value <.0001 <.0001
Role Emotional (RE)
 Baseline 21.6 (0.83) 21.1 (1.18) 0.46 (−2.33, 3.25) 0.7472
 Post 33.6 (0.97) 23.9 (1.56) 9.71 (6.08, 13.33) <.0001
 Difference (Post-Baseline) 12.01 (9.70, 14.31) 2.76 (−0.89, 6.40) 9.25 (4.98, 13.51) <.0001
 p-value <.0001 0.1377
Vitality (VT)
 Baseline 32.8 (0.82) 29.8 (0.99) 2.96 (0.38, 5.54) 0.0243
 Post 44.6 (0.75) 35.9 (1.39) 8.67 (5.68, 11.67) <.0001
 Difference (Post-Baseline) 11.78 (9.93, 13.63) 6.07 (2.88, 9.25) 5.71 (2.13, 9.29) 0.0018
 p-value <.0001 0.0002
Social Functioning (SF)
 Baseline 24.2 (0.81) 23.8 (1.16) 0.38 (−2.36, 3.12) 0.7852
 Post 35.5 (0.90) 29.0 (1.55) 6.51 (3.05, 9.97) 0.0002
 Difference (Post-Baseline) 11.35 (9.40, 13.30) 5.22 (1.80, 8.64) 6.13 (2.29, 9.97) 0.0018
 p-value <.0001 0.0028
Open in a new tab
1

Standard Error (SE) reported for means at Baseline and Post, 95% Confidence Interval (CI) reported for Difference from Baseline scores.

The post-ECT SF-36 measurements were consistently and positively related to baseline scores and remitter/non-remitter status or change in HRSD24 total score from baseline. The post-ECT SF-36 General Health measurement was positively related to age, while the Physical Functioning subscale was negatively related to age. The presence of psychotic symptoms was positively related to the post-ECT Physical Component Summary score and the Physical Functioning Subscale, but psychosis was negatively related to the Social Functioning Subscale. There were no statistically significant relationships between post-ECT SF-36 subscales or summary scores and estimates of premorbid intellectual ability, change in global cognitive function, or change from baseline in delayed recall or retention of verbal information (Table 4). The change in the DRS-2 I/P score was collinear with the MMSE and thus was removed from the analytic models.

Table 4.

Beta coefficients from linear regression investigating potential predictors of quality of life (SF-36 subscale and summary scores) by remitter status

OUTCOME β-coefficients
SF-36 T-SCORE Baseline Score Remitter HRSD1 MMSE1 WTAR Delayed Recall1 % Retention1 Age Psychosis
Physical Factors
 Physical Component Summary (PCS) 0.59**** NA −0.15* 0.19 0.02 0.64 −0.00 4.50*
 Bodily Pain (BP) 0.51**** NA −0.22** 0.39 0.02 0.31 −0.01
 Role Physical (RP) 0.51**** NA −0.22** −0.03 0.02 0.40 −0.00
 General Health (GH) 0.52**** NA − 0.41**** 0.15 0.01 0.60 −0.00 0.18*
 Physical Functioning (PF) 0.55**** NA −0.14* −0.05 0.04 0.76 −0.00 − 0.23* 5.41*
Mental Factors
 Mental Component Summary (MCS) 0.46**** 9.66**** NA −0.26 −0.10 0.09 −0.00
 Mental Health (MH) 0.35**** 9.19**** NA −0.26 −0.04 0.51 −0.00
 Role Emotional (RE) 0.30** NA − 0.32*** −0.18 −0.00 −0.49 −0.01
 Vitality (VT) 0.30*** 7.16**** NA −0.00 −0.07 1.22 −0.00
 Social Functioning (SF) 0.50* NA −0.25** −0.06 −0.10 0.21 −0.01 −5.28*
Open in a new tab

HRSD was not used in factors with questions related to depression, instead, Remitter status was used

Baseline score, Remitter status or HRSD, MMSE, WTAR, Delayed Recall, and Percent Retention remained in model regardless of covariate p-value significance.

Age and/or Psychosis only remained in the model if covariate p-value was significant (<0.05).

1

Change from baseline score (Last minus Baseline score)

*

p-value <0.05;

**

p-value <0.01,

***

p-value <0.001,

****

p-value <0.0001

Discussion

The main overall finding of this analysis is that the acute effects of an ECT course, when combined with venlafaxine, produces a marked improvement in HRQOL in elderly patients with MDD that is similar to what has been described in mixed-age samples. Participants had very poor HRQOL at baseline, and improved HRQOL was seen immediately at the conclusion of an ECT course combined with venlafaxine. Participants who remitted showed greater improvement in HRQOL. Notably, in this study, no decline in HRQOL was observed in any group. Final HRQOL status was closely related to both baseline HRQOL and remission/non-remission status, but was unrelated to cognitive function. The finding of superior physical health and physical functioning after ECT in those participants with baseline psychotic symptoms is consistent with earlier reports from our team that found that psychotic symptoms in the setting of MDD were a good prognostic factor for remission with ECT.(Petrides et al., 2001) In contrast, the finding of poorer social functioning after ECT in those participants with pre-ECT psychotic symptoms is not entirely unexpected and suggests that psychotic symptoms are related to more enduring impairment of social relationships even after successful ECT.

This report is subject to a number of limitations. First, the generalizability of the findings are limited to elderly adults with MDD who were taking concomitant venlafaxine and low dose, as-needed lorazepam in the context of treatment with RUL UB ECT. Other forms of ECT, higher doses of benzodiazepines, or different concomitant psychotropic medications could have produced different results. Second, as this was an open label study with no comparison group, the improvement in HRQOL group could be related to regression to the mean, but this seems unlikely as the effect was so closely related to improvement in depression status. Finally, this report does not address longer term effects of ECT on HRQOL in the elderly. Longer term effects of ECT in HRQOL in elderly patients will be the subject of a later report.

There are several clinical implications of these findings. First, ECT providers and elderly patients with MDD treated with ECT can be confident that ECT will result in short-term improved HRQOL. Second, attainment of remission is the key to improving HRQOL. Third, any acute change in select cognitive functions may be unrelated to short-term change in HRQOL.

Highlights.

  • Health-related quality of life (HRQOL) is poor in elderly patients with major depressive disorder (MDD) who are referred for electroconvulsive therapy (ECT).

  • An acute course of high dose, right unilateral, ultrabrief pulse ECT is associated with improvements in HRQOL in elderly MDD patients immediately after the course of ECT.

  • Changes in HRQOL in elderly MDD patients after ECT are best explained by the antidepressant effect of ECT, and are not related to the cognitive side effects of ECT.

Acknowledgments

The authors thank the following persons for their assistance in this study: Ahmad Raza, M.D., Styliani Kaliora, M.D., Vassilios Latoussakis, M.D., Kristen G. Tobias, M.A., Mimi C. Briggs, B.A., Lauren S. Liebman, B.A., Emma T. Geduldig, B.A., Abeba Teklehaimanot, M.S.

Footnotes

☆

This work was supported by NIMH grant U01MH055495-09 (Mt Sinai); U01MH055495-09., 1U01MH086127-01 (Wake Forest); 7U01MH086127 and 3U01MH086127-06S1 (Medical College of Georgia); U01MH081362 (Medical University of South Carolina); 5U01-MH086122 (Weill Cornell Medicine ); 5U01MH84241-5 (Duke); 5U01MH086130 (Mayo); 5U01MH08612005 (UTSW); U01 MH084241 (Duke); U01-MH086123 (LIJ)

Dr. McCall has been a scientific advisor for Merck, and Israeli Growth Partners, and a consultant to Luitpold Pharmaceuticals, Inc and Multiple Energy Technologies, LLC. Dr. Kellner receives honoraria from UpToDate, Psychiatric Times, and Northshore-LIJ Health System, and is a consultant to Luitpold Pharmaceuticals, Inc. Dr. Husain has received grant support from NIDA, NINDS, NIA, NARSD, Stanley Foundation, Cyberonics, Neuronetics, St. Jude medical (ANS), MagStim, Brainsway, NeoSync, Alkermes, and Corcept, and has been a consultant to Cerebain Inc. Dr. Young is a consultant to the NIH. Dr. Lisanby has received grant support from NINDS, NIBIB, Brain and Behavior Research Foundation, Stanley Medical Research Foundation, Neosync, Nexstim, and Brainsway. Dr. Petrides has received research support from Amgen, Astra Zeneca, Corcept, Eli Lilly, Proteus, St. Jude Medical, and Sunovion, and he has served on an advisory panel for Corcept. Dr. McClintock has received grant support from the NIH/NIMH and honoraria from TMS Health Solutions. The other authors report no financial relationships with commercial interests.

Clinical Trials.gov NCT01028508

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  • 1.Antunes P, Fleck M. Clinical outcomes and quality of life in patients submitted to electroconvulsive therapy. Journal of ECT. 2009;25:182–185. doi: 10.1097/YCT.0b013e318190b2a9. [DOI] [PubMed] [Google Scholar]
  • 2.D’Elia G, Raotma H. Is unilateral ECT less effective than bilateral ECT? Br J Psychiatry. 1975;126:83–89. doi: 10.1192/bjp.126.1.83. [DOI] [PubMed] [Google Scholar]
  • 3.Delis D, Kaplan E, Kramer J, Ober B. California Verbal Learning Test-Second Edition (CVLT-II). Manual. The Psychological Corporation; San Antonio: 2000. [Google Scholar]
  • 4.Folstein MF, Folstein SE, McHugh PR. “Mini-mental state” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12(3):189–198. doi: 10.1016/0022-3956(75)90026-6. [DOI] [PubMed] [Google Scholar]
  • 5.Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56–62. doi: 10.1136/jnnp.23.1.56. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Kellner CH, Husain MM, Knapp RG, McCall WV, Petrides G, Rudorfer MV, Young RC, Sampson S, McClintock SM, Mueller M, Prudic J, Greenberg RM, Weiner RD, Bailine SH, Rosenquist PB, Raza A, Kaliora S, Latoussakis V, Tobias KG, Briggs MC, Liebman LS, Geduldig ET, Teklehaimanot A, Lisanby SH the CORE/PRIDE Work Group. Right unilateral ultrabrief pulse electroconvulsive therapy (ECT) in geriatric depression: phase 1 of the PRIDE study. American Journal of Psychiatry. 2016 doi: 10.1176/appi.ajp.2016.15081101. epub before print: appiajp201615081101. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 7.Kotwicki R, Harvey P. Systematic study of the structured diagnostic procedures in outpatient psychiatric rehabilitation: a three-year, three-cohort study of thi stability of psychiatric diagnoses. Innovations in Clinical Neuroscience. 2013;10:14–19. [PMC free article] [PubMed] [Google Scholar]
  • 8.Lezak M, Howieson D, Loring D, Hannay J, Fischer J. Neuropsychological assessement. Oxford University Press; New York: 2004. [Google Scholar]
  • 9.Linn B, Gurel L. Cumulative illness rating scale. J Am Geriatr Soc. 1986;16:622–626. doi: 10.1111/j.1532-5415.1968.tb02103.x. [DOI] [PubMed] [Google Scholar]
  • 10.Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, Abraham J, Adair T, Aggarwal R, Ahn S, Alvarado M, Anderson HR, Anderson LM, Andrews KG, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012;380:2095–2128. doi: 10.1016/S0140-6736(12)61728-0. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 11.McCall WV, Rosenquist PB, Kimball J, Haskett R, Isenberg K, Prudic J, Lasater B, Sackeim HA. Health-related quality of life in a clinical trial of ECT followed by continuation pharmacotherapy: effects immediately after ECT and at 24 weeks. J ECT. 2011;27:97–102. doi: 10.1097/YCT.0b013e318205c7d7. [DOI] [PubMed] [Google Scholar]
  • 12.McCall WV, Cohen W, Reboussin B, Lawton P. Effects of mood and age on quality of life in depressed inpatients. J Affect Disord. 1999a;55(2–3):107–114. doi: 10.1016/s0165-0327(98)00204-3. [DOI] [PubMed] [Google Scholar]
  • 13.McCall WV, Cohen W, Reboussin B, Lawton P. Pretreatment differences in specific symptoms and quality of life among depressed inpatients who do and do not receive electroconvulsive therapy: a hypothesis regarding why the elderly are more likely to receive ECT. J ECT. 1999b;15(3):193–201. [PubMed] [Google Scholar]
  • 14.McCall WV, Dunn AG, Rosenquist P, Hughes D. Proxy validation of patient self-reports of ADL and IADL function before and after electroconvulsive therapy. J ECT. 2002;18(2):74–79. doi: 10.1097/00124509-200206000-00002. [DOI] [PubMed] [Google Scholar]
  • 15.McCall WV, Reboussin BA, Cohen W, Lawton P. Electroconvulsive therapy is associated with superior symptomatic and functional change in depressed patients after psychiatric hospitalization. J Affect Disord. 2001;63(1–3):17–25. doi: 10.1016/s0165-0327(00)00167-1. [DOI] [PubMed] [Google Scholar]
  • 16.McCall W, Dunn A, Rosenquist PB. Quality of life and function after ECT. British Journal of Psychiatry. 2004;(185):405–409. doi: 10.1192/bjp.185.5.405. [DOI] [PubMed] [Google Scholar]
  • 17.McCall W, Dunn A. Cognitive deficits are associated with functional impairment in severely depressed patients. Psychiatry Res. 2003;121:179–184. doi: 10.1016/j.psychres.2003.09.003. [DOI] [PubMed] [Google Scholar]
  • 18.McCall W, Reboussin D, Prudic J, Haskett R, Isenberg K, Olfson M, Rosenquist PB, Sackeim H. Poor health-related quality of life prior to ECT in depressed patients normalizes with sustained remission after ECT. Journal of Affective Disorders. 2013;147:107–111. doi: 10.1016/j.jad.2012.10.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 19.McCall WV, Prudic J, Olfson M, Sackeim HA. Health-related quality of life following ECT in a large community sample. Journal of Affective Disorders. 2006;90:269–274. doi: 10.1016/j.jad.2005.12.002. [DOI] [PubMed] [Google Scholar]
  • 20.Petrides G, Fink M, Husain M, Knapp R, Rush A, Mueller M, Rummans T, O’Connor K, Rasmussen K, Bernstein H, Biggs M, Bailine S, Kellner C. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT. 2001;17:244–253. doi: 10.1097/00124509-200112000-00003. [DOI] [PubMed] [Google Scholar]
  • 21.Rhebergen D, Huisman A, Bouckaert F, Kho K, Kok R, Sienaert P, Spaans HP, Stek m. Older age is associated with rapid remission of depression after electroconvulsive therapy: a latent class analysis. American Journal of Geriatric Psychiatry. 2015;23:274–282. doi: 10.1016/j.jagp.2014.05.002. [DOI] [PubMed] [Google Scholar]
  • 22.Sackeim HA, Dillingham E, Prudic J, Cooper T, McCall WV, Rosenquist P, Isenberg K, Garcia K, Mulsant BH, Haskett RF. Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes. Archives of General Psychiatry. 2009;66:729–737. doi: 10.1001/archgenpsychiatry.2009.75. [DOI] [PubMed] [Google Scholar]
  • 23.Sheehan D, Lecrubier Y, Harnett-Sheehan K, Amorim P, Janavs J, Weiller E, Hergueta T, Baker R, Dunbar G. The Mini International Neuropsychiatric Interview (M.I.N.I.) the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry. 1998;59(supplement 20):22–33. [PubMed] [Google Scholar]
  • 24.Sheehan D, Lecrubier Y, Sheehan K, Janavs J, Weiller E, Schinka J, Knapp E, Sheehan M, Dunbar GC. The validity of the Mini International Neuropsychiatric Interview (MINI) according to SCID-P and its reliability. European Psychiatry. 1997;12:232–241. [Google Scholar]
  • 25.Spitzer RL, Williams JB, Gibbon M, First MB. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry. 1992;49(8):624–629. doi: 10.1001/archpsyc.1992.01820080032005. [DOI] [PubMed] [Google Scholar]
  • 26.Tew J, Mulsant B, Haskett R, Prudic J, Thase M, Crowe R, Dolata D, Begley A, Reynolds C, Sackeim H. Acute efficacy of ECT in the treatment of major depression in the old-old. American Journal of Psychiatry. 1999;156(12):1865–1870. doi: 10.1176/ajp.156.12.1865. [DOI] [PubMed] [Google Scholar]
  • 27.Ware JE, Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I Conceptual framework and item selection. Med Care. 1992;30(6):473–483. [PubMed] [Google Scholar]
  • 28.Ware J, Kosinski M. How to score version 2 of the SF36 Health Survey (Standard and acute forms) Quality Metric Incorporated; Lincoln, RI: 2000. [Google Scholar]
  • 29.Ware J, Kosinski M, Gandek B. SF-36 Health Survey: Manual & Interpretation Guide. QualityMetric Incorporated; Lincoln, RI: 2003. [Google Scholar]
  • 30.Wechsler D. The Wechsler Test of Adult Reading (WTAR) The Psychological Corporation; San Antonio, Tx: 2001. [Google Scholar]
  • 31.WHO Guidelines Approved by the Guidelines Review Committee. World Report on Disability 2011. Geneva: World Health Organization; 2011. [Google Scholar]
  • 32.Woods S, Delis D, Scott J, Kramer J, Holdnack J. The California Verbal Learning Test--second edition: test-retest reliability, practice effects, and reliable chnage indices for tehstandard and alternative forms. Archives Clin Neuropsychol. 2006;21:413–420. doi: 10.1016/j.acn.2006.06.002. [DOI] [PubMed] [Google Scholar]

RESOURCES