Open Journal of Depression
2012. Vo1.1, No.2, 9-14
Published Online November 2012 in SciRes (http://www.SciRP.org/journal/ojd) http://dx.doi.org/10.4236/ojd.2012.12002
Treating Depression with ECT: An Objective Review
Basem Gohar1,2, Christa R. Winter1, Mark Benander3, Barbara Mandell1,
Cassandra Hobgood2, Keith Z. Brewster4
1Department of Psychology, Springfield College, Springfield, USA
2Department of Psychiatry, Baystate Health, Springfield, USA
3Department of Psychology, Baypath College, Longmeadow, USA
4Department of Health and Exercise Science, University of Br itish Columbia, Kelowna, Canada
Received September 27th, 2012; revised October 29th, 20 12 ; ac cep te d No ve mber 8th, 2012
The current study examined the efficacy of Electroconvulsive Therapy (ECT) as a treatment method for
unipolar and bipolar depression using an objective measure through a retrospective chart review. First,
this article discusses the history of ECT as well as issues in psychiatric diagnoses. Patients’ progress in
this study was measured by the hospital’s psychiatrists as well as through the self-report measure, Clini-
cally Useful Depression Scale (CUDOS). The sample consisted of 22 female and 8 male depressed inpa-
tients and outpatients. A 2 × 2 mixed ANOVA revealed a significant interaction, showing improvement
from pre-treatment to post-treatment in both genders. In post-treatment, female patients showed signifi-
cantly more improvement than male patients. This study suggests that ECT results in depression reduction,
especially in female patients. In addition, the CUDOS has shown to be a simple and effective self-report
measure in assessing progress of depression including complex treatments, such as ECT. Recommenda-
tions for future ECT studies include: controlling for comorbidity and medication by obtaining a larger
sample size to categorize patients according to medication type and dosage.
Keywords: Electroconvulsive Therapy; Depression; Self-Report Measure; Objectivity
Introduction
Depression is a mental disorder that is currently on the rise.
Kessler, McGonagle, Nelson, Hughes, Swartz, and Blazer (19-
94) conveyed that approximately one in five individuals in the
general population face at least one major depressive episode.
Moreover, Kessler, Aguilar-Gaxiola, Alonso, Chatterji, Lee,
and Üstun (2009) indicated in an analysis of the National Co-
morbidity Survey Replication that the prevalence of the disor-
der among adults in the United States is 16.2%, which is the
most common and costly illness. Additionally, Murray and
Lopez (1996) indicated that major depressive disorder (MDD)
was listed as the fourth ranked cause of premature death
worldwide.
There are different types of depression as listed in The Di-
agnostic and Statistical Manual of Mental Disorders (DSM-IV-
TR; American Psychiatric Association, 2000). Some of the sy-
mptoms of depression include feeling sad or tearful, change in
appetite, sleep and energy, inability to concentrate, suicidal idea-
tions, feeling worthless, loss of interest or pleasure in activities
which used to give pleasure, and psychomotor agitation. Causes
of depression might differ for each individual. Some research-
ers suggested that depression is solely genetic-based (Campbell
& MacQueen, 2006; Hasler, Drevets, Manji, & Charney, 2004;
Penttila et al., 2004; Ressler & Mayberg, 2007; Ruhé, Mason,
& Schene, 2007). Other researchers suggested that it is due to a
joint contribution of genetic and environmental factors such as
major life stressors (Cervilla et al., 2007; Duman & Monteggia,
2006; Kendler, Gatz, Gardner, & Pederse, 2006; Kim, Stewart,
Kim, Yang, & Shin, 2007; Rot, Mathew, & Charney, 2009).
Rot et al. concluded that depression is caused by a cumulative
impact of genetics, adverse events in childhood and ongoing or
recent stress. These findings portray that gene-environment in-
teractions could better predict the risk of developing depression
better than genes or environment alone.
Electroconvulsive therapy (ECT) is considered to be a last
resort in treating depression; after failing to see results with
medication and psychotherapy. Nevertheless, ECT is conside-
red as one of the most effective treatments for depression
(American Psychiatric Association, 2000; Sackeim, Prudic,
Fuller, Keilp, Lavori, & Olfson, 2006; Yatham et al., 2010). It
has been stated, “The results of ECT in treating severe depres-
sion are among the most positive treatment effects of all of
medicine” (Dukakis & Tye, 2006: p. 132). Di Pauli and Conca
(2009) described ECT as a required, induced suprathreshold
stimulus in order to achieve therapeutic seizure. According to
Beyer, Glenn, and Weiner (1998), ECT has proved to be effect-
tive since the 1930s. Keddy and Erdberg (2010) noted that ECT
has been on the rise, with more than 100,000 Americans re-
ceiving treatment annually and approximately up to 20 times
that many globally. ECT, however, is also considered to be one
of the most controversial types of treatment in mental health
(MacQueen, Parkin, Marriott, Begin, & Hasey, 2007). Despite
the treatment’s efficacy, persistent fears, misunderstandings,
and stereotypes continue.
ECT Overview
History of EC T
The notion behind inducing seizure as a treatment was ex-
ploited in 1934 (Beyer et al., 1998). Neuropsychiatrist, Ladislas
Joseph von Meduna posited that individuals with epilepsy were
saved from psychotic symptoms of schizophrenia (Fink, 1984).

B. GOHAR ET AL.
Meduna speculated that the use of convulsions in schizophrenic
patients would reduce symptoms. The initial use of convul-
sion was done pharmacologically, using intramuscular inject-
tions of Camphor and Metrazol, which promoted seizures. Fink
elucidated that Meduna’s clinical trials demonstrated a signifi-
cant decrease in psychotic symptoms. However, it was later
revealed that there was no significant correlation between epi-
lepsy and psychosis. Additionally, it was found that pharma-
cological methods to induce seizures had copious side effects.
Neuropsychiatrists, Ugo Cerletti and Lucio Binni introduced
the use of electricity to induce seizures in 1937 (Accornero,
1988). They discovered that using electricity was more effec-
tive and safer than pharmacological agents. Babigian and Gutt-
macher (1984) acknowledged the popularity of ECT treatment,
however the reputation of the treatment began to diminish dur-
ing the 1950s. They credited the insufficiency of the treatment
to the discoveries of medications treating depressive, manic,
and psychotic symptoms. In addition to discoveries of medica-
tion, it was believed that the media was a leading cause for the
disrepute of the treatment. Films, such as One Flew Over the
Cuckoo’s Nest, which was produced in 1975, showcased ECT
as an act of ruthless behavioral punishment (Jenkusky, 1992).
ECT Today
Presently, ECT is slowly earning a positive reputation and is
used for a variety of mental health reasons (Beyer et al., 1998).
ECT is used mainly for patients suffering from unipolar and
bipolar depression, psychotic disorders, as well as with preg-
nant patients with severe symptomology in the event that the
necessary medication is contraindicated for fetal health. While
ECT has shown to be successful, there are a variety of factors
that must be accounted for to avoid adverse effects (Le Strat &
Gorwood, 2007). Beyer et al. (1998) reported that the mortality
rate in ECT is low. The researchers also reported that no con-
traindications have been researched for ECT. However, there
are factors that could increase the risk of complications and
adverse effects medically and cognitively.
From a medical perspective, ECT could be considered higher
in risk if there are any irregularities found in the brain, such as
detecting a tumor or hematoma (Beyer et al., 1998). Other con-
ditions include recent myocardial infractions, intracerebral
hemorrhage, unstable vascular aneurysm or malformation, or
anesthetic complications. The researchers highlighted that a sig-
nificant positive correlation is found between mortality rate and
those with comorbid medical diseases, specifically cardiovas-
cular and respiratory diseases.
Cognitively, the researchers outlined three potential im-
pairments (Beyer et al., 1998). First is postictal confusion, which
is a brief state of confusion that lasts from minutes to hours
after patients awaken from ECT treatment. Daniel and Crovitz
(1986) identified a variety of factors that could affect postictal
confusion. Risks of postictal confusion are higher when sine
waves, stimulus intensity and frequency in treatment increase.
Advancing age was also seen as a predictor. However, a meta-
analysis by Flint and Gagnon (2002) found a positive correla-
tion between ECT efficacy and advancing age. They explained
that age is not the cause of postictal confusion; however, it is
the age-related neurological conditions (e.g. dementia) that are
attributed to the cognitive deficits. Thus, proper evaluations are
necessary for older patients prior to treatment.
The second type of cognitive impairments that could occur
with ECT is interictal confusion, which Beyer et al. (1998) des-
cribed as a more serious state of confusion that develops into a
state of delirium. Interictal confusion however is found to be
uncommon. Memory dysfunctions, such as retrograde amnesia
are also possible outcomes. In addition, electrode placements in
ECT may contribute to short-term or long-term adverse effects.
For example, unilateral placement poses less postictal deficits
post treatment, however, is normally found to be less effective
than bitemporal (Sackeim et al., 2006). While bitemporal has
been shown to be more effective, cognitive outcomes could be
more potent and long lasting, such as retrograde amnesia.
Diagnosis
Vis-à-vis diagnosis and progress examinations in a psychiat-
ric capacity, psychiatrists are experts and skilled professionals
who are meticulous in their assessments. They gather the nec-
essary information directly through interviews with patients and
indirectly through case discussions in multidisciplinary treat-
ment teams as well as reviewing prior documents pertinent to
the patient. Consequently, this has raised concerns for potential
subjectivity, as detecting and perceiving sy mpto ms of mental dis-
orders can be exceptionally imprecise. Engel (1977), the foun-
der of the biopsychosocial model for medicine explained that
the field of psychiatry is ambiguous and “in contrast, the rest of
medicine appears neat and tidy. It has a firm base in biological
sciences and its command, and a record of astonishing achiev-
ing in elucidating mechanisms of disease and devising new
treatments” (Engel, 1977: p. 129).
The concern of subjectivity remains an issue in more recent
literature. Bloch, Ratzoni, Mendlovic, Gal, and Levkovitz (2005)
criticized the inconsistencies in determining maximal medical
improvement (i.e. returning to baseline through treatment) of
patients with mental disorders across the literature. Therefore,
measuring progress, especially with a treatment such as ECT
would benefit from the inclusion of an objective and standardi-
zed approach in addition to the psychiatrists’ assessments. Zi-
mmerman and Mattia (2001) accentuated the importance of ac-
curate, reliable, valid, and accessible measures in evaluating the
quality and efficiency of care in clinical practice. Thus, stan-
dardized measures such as self-reported instruments that meas-
ure fluctuating affective states in psychiatric patients are nec-
essary. The researchers described self-report questionnaires as a
cost-effective option because they are inexpensive and require
less time for completion. In addition, the researchers pointed
out that the results of self-report questionnaires correlate highly
with the ratings of clinicians.
Among the newer self-report questionnaires used today is the
Clinically Useful Outcome Depression Scale (CUDOS, Zim-
merman, Chelminski, McGlinchey, & Posternak, 2008). The
questionnaire consists of 18 items. Of those items, 16 assess all
of the DSM-IV-TR (American Psychiatric Association, 2000)
inclusion criteria for MDD and dysthymic disorder. The two
remaining items examine psychosocial impairment and quality
of life. It takes approximately three min to complete by the
patient and about 15 s to score by the clinician, which works
well in the ECT treatment setting, where it would not aggravate
the patients prior to the procedure. Psychometric properties of
the CUDOS are discussed in the methods section.
The present study was designed to objectively examine
symptoms of depression in previous patients who were under-
10

B. GOHAR ET AL.
going ECT. Initial and final scores of the CUDOS in a course
of treatment were gathered retrospectively from depressed pa-
tients who have undergone ECT.
Methods
The Institutional Review Boards of Baystate Health (BH) as
well as Springfield College in Springfield, MA approved this
study.
Sample
Data were collected from archived records of patients at BH
from September 2010 to January 2012. The sample consisted of
30 former inpatients and outpatients at BH, who required ECT
for treatment due to depression, failed to reach maximal medi-
cal improvement by medication and therapy, and who received
a minimum of four treatments in one series of ECT. In this
study, patients were diagnosed with unipolar or bipolar depres-
sion.
ECT
Unilateral or bilateral (bitemporal) electrodes were placed on
patients based on the psychiatrists’ impressions prior to treat-
ment using the MECTA 5000Q device at BH. Typically, pa-
tients received three treatments per week, as is the clinical cus-
tom at BH and in the United States.
Measure
In this study, the researchers examined previous scores of the
CUDOS (Zimmerman et al., 2008) in former depressed patients
of the hospital who had undergone ECT treatment. Zimmerman
et al. tested the reliability and validity of the CUDOS on 1475
participants. Of those participants, 42.4% were diagnosed with
MDD. The CUDOS displayed strong internal consistency in
sample with alpha of .90. The test-retest reliability of the CU-
DOS was established with 176 participants at baseline (r = .92)
and 33 participants during follow-up (r = .95). Pertaining to
validity, 200 participants were given a variety of mood disorder
questionnaires including CUDOS to be completed. The re-
searchers discovered that CUDOS was highly correlated with
the Beck’s Depression Inventory (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961) than with measures of other symptom
domains, which indicates strong discriminant validity. The
psychiatrists at BH favor the CUDOS and use the questionnaire
as a part of the progress evaluations as it correlates with their
evaluations and takes little time to complete by the patient and
to score by the psychiat rists.
Procedure
The researchers created a raw score sheet. This sheet did not
contain any Health Insurance Portability and Accountability
Act (HIPPA) information pertaining to the patient, as it was
de-identified information. The researchers organized the in-
formation obtained from the database of the hospital, which
included: (a) codes given to patients (e.g. ECT1), (b) age, (c)
gender, (d) pre-scores of CUDOS (Zimmerman et al., 2008),
and (e) post-scores of the CUDOS. Pre-scores were the pa-
tients’ outcome measures prior to their first ECT session in a
course of treatment. Post-scores were their outcome measures
prior to their last ECT session in a course of treatment.
Statistical Analyses
Descriptive statistics were used to describe participants in the
study. A 2 × 2 mixed factorial Analysis of Variance (ANOVA)
was computed to compare pretest and posttest scores of the
CUDOS (Zimmerman et al., 2008) as well as gender. Tukey-
Kramer post hoc tests were used to follow up significant find-
ings
Results
Basic assumptions for conducting the mixed factorial ANO-
VA were met, except homogeneity of variance was not sup-
ported for the CUDOS (Zimmerman et al., 2008) scores post
intervention (p = .03). A total of 30 patients were selected from
the archived records of the hospital; 22 (age M = 51.78; SD =
12.82) were female patients and 8 (age M = 53.38; SD = 14.99)
were male pati ents. Descript ive statistics for age and number of
treatments based on gender of the sample are presented in Ta-
ble 1. Pre-scores and post-scores of the CUDOS and gender
were analyzed using a 2 × 2 mixed factorial ANOVA. The in-
dependent group variable was gender (male and female). The
repeated measures factor was test occasion (pretest and post-
test). The dependent variable was depression, which was meas-
ured by the CUDOS. Mean scores of the CUDOS (pre and post)
by gender are presented in Table 2.
The 2 × 2 mixed factorial ANOVA revealed a significant in-
teraction between test occasion and gender F(1, 28) = 5.87, p
= .02. A summary of the 2 × 2 mixed factorial ANOVA is pre-
sented in Table 3. Due to the significant interaction, Tukey-
Kramer post hoc tests were conducted. Three post hoc com-
parisons were significant. First, there was a significant im-
provement (p < .05) from pretest (M = 46.25; SD = 8.58) to
posttest scores (M = 33.63; SD = 20.23) in male patients. Simi-
lar findings were found in female patients, who also showed
significant improvement (p < .05) from pretest (M = 49.68; SD
= 11.03) to posttest (M = 23.32; SD = 12.44). Lastly, a signifi-
cant difference (p < .05) was found in posttesting, with female
patients (M = 23.32; SD = 12.44) showing significantly lower
scores than male patients (M = 33.63; SD = 20.23). No signifi-
cant difference (p > .05) was found in the pretest scores be-
tween male and female patients.
Discussion
The current study was designed to determine the effects of
ECT on patients suffering from depression through a retrospect-
tive chart review in an objective approach by examining scores
of the CUDOS (Zimmerman et al., 2008) prior to first and at
the end treatment in a series. The results of the study showed a
reduction in levels of depression, as indicated by the change of
scores of the CUDOS after the completed ECT treatment. Thus,
the results of this study support the efficacy of ECT in patients
suffering from depression. Using a standardized method for
each patient was helpful in this study when examining progress.
Gilbody, House, and Sheldon (2002) reported that the use of
standardized and quantifiable outcome measures is useful. How-
ever, they noted that they are rarely used in routine clinical pra-
ctice.
It is important to note that the initiative behind using an ob-
jective measure is not to replace the psychiatrists’ evaluations,

B. GOHAR ET AL.
Table 1.
Descriptive statistics of patients’ age, number of treatments, and mean
seizure length based on gender of the sample (N = 30).
Variable Mean SD Minimum Maximum
Age
Male 53.38 14.99 31 73
Female 51.78 12.82 33 77
Number of
Treatments
Male 7.77 1.83 5 11
Female 7.75 3.79 4 18
Note. Male n = 8, Female n = 22
Table 2.
Descriptive statistics of patients’ CUDOS Scores Pre and post ECT
treatment in series (N = 30).
Gender n Mean SD Minimum Maximum
Pre CUDOS
Male 8 46.25 8.58 32 65
Female 22 49.68 11.03 27 57
Total 30 48.77 10.40
Post CUDOS
Male 8 33.63 20.23 3 60
Female 22 23.32 12.44 4 44
Total 30 26.07 15.24
Table 3.
2 × 2 mixed factorial ANOVA comparing gender and test occasion of
CUDOS before and after ECT treatment (N = 30).
Source SS df MS F p
Between
Groups
Group 69.23 1 6.23 .59 .45
Error 3273.22 28 116.87
Within Subjects
Occasion 8918.00 1 8918.00 47.80 .00
A × B 1107.33 1 1107.33 5.87 .02
Error 5280.97 28 188.61
but to simply reduce any form of subjectivity that may arise.
Further, the process of ECT cannot be entirely left for stan-
dardized measures. For example, the psychiatrists determine the
placement of the electrodes for each patient prior to treatment, a
clinical judgement that is based on knowledge and experience.
Due to the complexity of each case, the psychiatrists must se-
lect the best option for each patient; striving to deliver the low-
est level of risk in conjunction with the highest degree of bene-
fit. Other factors that psychiatrists must consider for ECT in-
clude, but are not limited to: electrode placement, age, stimulus
intensity, sine wave intensity, treatment frequency, medication
use, and medical conditions (Beyer et al., 1998).
The inclusion of standardized measures in the process of
ECT however generates a number of benefits. A self-report
measure as simple as The CUDOS (Zimmerman et al., 2008)
provides a clear and visible objective measure to the patients
and their loved ones in order to monitor progress. A standard-
ized measure is also helpful in supporting the decision of the
psychiatrists’ progress assessments in two ways. It could sup-
port the decision to terminate treatment based on a patient
reaching maximal medical improvement, which would be noti-
ceable by viewing a reduction in the CUDOS scores. It could
also support the decision to terminate treatment if a patient is
not showing improvement, as the CUDOS scores would margi-
nally decrease, remain the same, or increase.
The results of this study suggest that both male and female
patients had significant improvement after ECT series. How-
ever, female patients showed more improvement than male
patients, evidenced by the scores on the CUDOS (Zimmerman
et al., 2008). This finding resembles the findings of Bloch et al.
(2005), who determined that female schizophrenic patients had
significantly more improvement than male schizophrenic pa-
tients after ECT treatments. Therefore, female patients with
schizophrenia and depression show more improvement than
male patients after ECT. Although depression diagnoses are
classified as mood disorders and schizophrenia is classified as a
psychotic disorder, the disorders share similarities in improve-
ment using the same treatment. For example, Mahmoud et al.
(2007) found improvement in both types of disorders using the
same medication. They determined that the use of antipsychotic
medications such as Risperdal has been effective in treating
MDD.
Difference in improvement between genders however could
be attributed to the difference in depressive symptoms presen-
ted based on gender. For example, Gorman (2006) examined
the difference of displaying sadness between men and women.
The researchers found that women displayed more visible emo-
tions of sadness (e.g. crying) than men, who were more rigid. In
another study, Winkler, Pjerk, and Kasper (2006) reported that
men displayed depression in a more aggressive and irritable
behavior than women. Thus, ECT might be more effective in
treating symptoms displayed by women more than those dis-
played by men. Also, female patients might have shown better
improvement based on the reports of the depressive symptoms.
Winkler et al. reported that female patients had more visits to
their doctor regarding symptoms of depression and anxiety than
male patients. Therefore, female patients showing more im-
provement than male patients could be attributed to earlier in-
tervention, more frequent consultations, and greater engage-
ment with health professionals. As a result, the current finding
questions the differences in manifestations as well as the chro-
nicity of the depression between genders prior to seeking pro-
fessional help. The possibilities listed above are speculations
due to the lack of literature with regards to gender differences
in ECT patients, specifically in patients suffering from depress-
sion. As a result, gender differences would benefit more explo-
ration in future studies with more and equal numbers of male
and female pat ient s.
There were some limitations to this study. First, depressed
patients might have presented different symptoms. Second, the
12

B. GOHAR ET AL.
duration of the disorder might have varied from one patient to
another. Third, as this was a retrospective chart review, the
researchers were unable to account for cognitive impairments
that might have occurred during the treatments. Therefore, it is
unknown whether cognitive deficits led to discontinuation of
the full series prior to reaching maximal medical improvement
for some patients. Despite the observed results of each patient,
even if CUDOS (Zimmerman et al., 2008) scores displayed im-
provement, it is unknown if the patient did truly meet maxi-
mal medical improvement. Therefore, this study cannot con-
clude that patients overall reached maximal medical improve-
ment. Alternatively, it can be concluded that patients, overall,
showed improvement after ECT treatments.
Fourth, the selection process delimited the study by selecting
patients who were diagnosed with a type of depression and
received a minimum of four ECT treatments in a series. How-
ever, this study did not control for comorbid psychiatric disor-
ders. Therefore, it is unknown if differences in progress were
due to comorbidity. This could be the case as Afifi (2005) noted
that patients with MDD commonly have a comorbid anxiety
disorder. Lastly, this study did not control for medication dur-
ing ECT treatment. Due to the nature of the treatment, it was
difficult to control for medication as each patient had different
circumstances medically and psychologically. Therefore, reco-
mmendations for future ECT studies include: controlling for co-
morbidity and medication, obtaining a larger sample size to
categorize patients according to medication type and dosage.
Conclusion
In conclusion, the findings of this study support the efficacy
of ECT in treating depression. More improvement was shown
in female patients than male patients. Lastly, the CUDOS has
shown to be a simple and effective self-report measure in as-
sessing progress of depression including complex treatments,
such as ECT. The measure is also helpful in providing a clear
and objective approach to measure treatment outcome.
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