Home Uncategorized Discussion: Using the Walden Library

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Discussion: Using the Walden Library

Where can you find evidence to inform your thoughts and scholarly writing? Throughout your degree program, you will use research literature to explore ideas, guide your thinking, and gain new insights. As you search the research literature, it is important to use resources that are peer-reviewed and from scholarly journals. You may already have some favorite online resources and databases that you use or have found useful in the past. For this Discussion, you explore databases available through the Walden Library.

To Prepare:

Review the information presented in the Learning Resources for using the Walden Library, searching the databases, and evaluating online resources.
Begin searching for a peer-reviewed article that pertains to your practice area and interests you.

By Day 3 of Week 6

Post the following:

Using proper APA formatting, cite the peer-reviewed article you selected that pertains to your practice area and is of particular interest to you and identify the database that you used to search for the article. Explain any difficulties you experienced while searching for this article. Would this database be useful to your colleagues? Explain why or why not. Would you recommend this database? Explain why or why not.

By Day 6 of Week 6

Respond to at least two of your colleagues’ posts by offering suggestions/strategies for working with this database from your own experience, or offering ideas for using alternative resources.

Discussion for reply one

The article I selected that pertains to my practice area and is of great interest to me is:

Men, Depression, and Coping: are we on the Right Patch? The citation of the article is as followed:

Whittle, E. L., Fogarty, A. S., Tugendrajch, S., Player, M. J., Christensen, H., Wilhelm, K., . . . Proudfoot, J. (2015). Men, depression, and coping: Are we on the right path? Psychology of Men & Masculinity, 16(4), 426-438. doi:10.1037/a0039024

I use the Walden University Library database for the article search using CINAHL Plus with Full Text, peer-reviewed article, evidence-based, full text within five years. I did not find any difficulties searching for this article. The database I believe would be useful to all my colleagues. It would be useful to my colleagues because it is trusted and well organized. The database is user friendly giving multiple options and resources for help. I would recommend this database, because of the integrity of the information sources. As a professional, and new to scholar writing, finding unbiased information for research is important to provide evidence-based research to my academic audience. This database is not open to everyone, it is private to Walden University students and faculty members. So, this database is secure with credible information. That is why I would recommend it.

References

JavaScript required. (n.d.). Retrieved October 06, 2020, from

https://web-b-ebscohost-com.ezp.waldenulibrary.org/ehost/detail/detail?vid=15

Laureate Education (Producer). (2018). Introduction to Scholarly Writing: Purpose, Audience, and Evidence [Video file]. Baltimore, MD: Author.

Discussion for reply two

Initial Discussion Post

Suarez, L., Dunlay, S. M., Schettle, S. D., Stulak, J. M., & Staab, J. P. (2020). Associations of depressive symptoms of outcomes in patients implanted with left ventricular assist devices. General Hospital Psychiatry, 64, 93-98.

https://doi.org/.ezp.waldenulibrary.org/10.1016/j.genhosppsych.2019.12.005

As a left ventricular assist device (LVAD) coordinator, I am always interested in providing my patients with the best options for holistic care, specifically focused on their perception of health. Implantation of these devices is to alleviate symptoms of end stage heart failure and improve patients’ quality of life (Lee, 2018). Therefore, this article really stood out to me as a beneficial study that could be used to shape my practice.

I was able to access the Walden University Library Fundamentals of Library Research page and I watched the online tutorial of accessing databases (Instructional media: Fundamentals of library research, 2020). After that, I followed the link to the Nursing Databases page in the Library and saw the list of databases offered. I opted for one that included full text articles from the list of ‘Best Bets’ (Databases: A-Z, 2020). I chose CINAHL and typed in my subject, left ventricular assist device and quality of life, in the search bars (Databases: A-Z, 2020). I was easily brought to a results page of articles to choose from.

I didn’t have much issue accessing these articles and finding one that met my intended need. I would definitely recommend the use of CINAHL as it was easy to use, filtered results appropriately, and provided full text articles with citation. My only hesitation is that I’m not sure how easy it would have been to find the list of nursing databases if I hadn’t followed the exact link that was provided in the recommended reading. I will need to do some navigation myself from the main Walden University webpage to find the best way to navigate to the databases home page. Once I am able to find the way there, I think I will be using this database a lot for future referencing. It is really great that Walden gives us access to all these articles at our fingertips. It is so much easier than having to go to the library and thumb through text. I will most definitely recommend this way to everyone that needs to do research going forward!

References

Databases A-Z: Nursing. (2020). Walden University Library. Retrieved September 27, 2020, from

https://academicguides.waldenu.edu/az.php?s=19981

Instructional Media: Fundamentals of library research. (2020). Walden University Library. Retrieved September 27, 2020, from

https://academicguides.waldenu.edu/library/instructionalmedia/researchfundamentals

Lee, C. S., Gelow, J. M., Chien, C. V., Hiatt, S. O., Bidwell, J. T., Denfeld, Q. E., Grady, K. L., & Mudd, J. O. (2018). Implant Strategy-Specific Changes in Symptoms in Response to Left Ventricular Assist Devices. Journal of Cardiovascular Nursing, 33(2), 144–151.

https://doi-org.ezp.waldenulibrary.org/10.1097/JCN.0000000000000430

Please label the replies and use the rubric

Main

Posting

—

Excellent 45 (45%) – 50 (50%)

Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.

Supported by at least three current, credible sources.

Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

Good 40 (40%) – 44 (44%)

Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.

At least 75% of post has exceptional depth and breadth.

Supported by at least three credible sources.

Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style.

Fair 35 (35%) – 39 (39%)

Responds to some of the discussion question(s).

One or two criteria are not addressed or are superficially addressed.

Is somewhat lacking reflection and critical analysis and synthesis.

Somewhat represents knowledge gained from the course readings for the module.

Post is cited with two credible sources.

Written somewhat concisely; may contain more than two spelling or grammatical errors.

Contains some APA formatting errors.

Poor 0 (0%) – 34 (34%)

Does not respond to the discussion question(s) adequately.

Lacks depth or superficially addresses criteria.

Lacks reflection and critical analysis and synthesis.

Does not represent knowledge gained from the course readings for the module.

Contains only one or no credible sources.

Not written clearly or concisely.

Contains more than two spelling or grammatical errors.

Does not adhere to current APA manual writing rules and style.

Main Post: Timeliness

—

Excellent 10 (10%) – 10 (10%)

Posts main post by day 3.

Good 0 (0%) – 0 (0%)

Fair 0 (0%) – 0 (0%)

Poor 0 (0%) – 0 (0%)

Does not post by day 3.

First Response

—

Excellent 17 (17%) – 18 (18%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues.

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

Good 15 (15%) – 16 (16%)

Response exhibits critical thinking and application to practice settings.

Communication is professional and respectful to colleagues.

Responses to faculty questions are answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

Fair 13 (13%) – 14 (14%)

Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed.

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

Poor 0 (0%) – 12 (12%)

Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.

Second Response

—

Excellent 16 (16%) – 17 (17%)

Response exhibits synthesis, critical thinking, and application to practice settings.

Responds fully to questions posed by faculty.

Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.

Demonstrates synthesis and understanding of learning objectives.

Communication is professional and respectful to colleagues.

Responses to faculty questions are fully answered, if posed.

Response is effectively written in standard, edited English.

Good 14 (14%) – 15 (15%)

Response exhibits critical thinking and application to practice settings.

Communication is professional and respectful to colleagues.

Responses to faculty questions are answered, if posed.

Provides clear, concise opinions and ideas that are supported by two or more credible sources.

Response is effectively written in standard, edited English.

Fair 12 (12%) – 13 (13%)

Response is on topic and may have some depth.

Responses posted in the discussion may lack effective professional communication.

Responses to faculty questions are somewhat answered, if posed.

Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited.

Poor 0 (0%) – 11 (11%)

Response may not be on topic and lacks depth.

Responses posted in the discussion lack effective professional communication.

Responses to faculty questions are missing.

No credible sources are cited.

Participation

—

Excellent 5 (5%) – 5 (5%)

Meets requirements for participation by posting on three different days.

Good 0 (0%) – 0 (0%)

Fair 0 (0%) – 0 (0%)

Poor 0 (0%) – 0 (0%)

Does not meet requirements for participation by posting on 3 different days.

Journal of Affective Disorders

202 (2016) 10–15

Contents lists available at ScienceDirect

Journal of Affective Disorders

http://d
0165-03

n Corr
E-m

journal homepage: www.elsevier.com/locate/jad

Research paper

Significantly improved neurocognitive function in major depressive
disorders 6 weeks after ECT

Christine Mohn a,n, Bjørn Rishovd Rund a,b

a Research Department, Vestre Viken Hospital Trust, Drammen, Norway
b Department of Psychology, University of Oslo, Oslo, Norway

a r t i c l e i n f o

Article history:
Received 18 November 2015
Received in revised form
2 February 2016
Accepted 12 March 2016
Available online 20 May 2016

Keywords:
Cognition
Depression
ECT
MCCB
Memory
Neuropsychology

x.doi.org/10.1016/j.jad.2016.03.062
27/

esponding author.
ail address: h.c.mohn@psykologi.uio.no (C. Mo

a b s t r a c t

Background: Cognitive side effects may occur after electroconvulsive treatment (ECT) in depressive
disorder patients. Previous studies have been limited by small numbers of cognitive functions assessed.
The present study reports the first results from a prospective project monitoring cognitive effects of ECT
using a comprehensive neuropsychological test battery and subjective report of everyday cognitive
function.
Methods: Thirty-one patients with major depressive disorder were assessed with the MATRICS Con-
sensus Cognitive Battery (MCCB). Subjective cognitive complaints were described with the Everyday
Memory Questionnaire (EMQ). Severity of depression symptoms were assessed with the Montgomery-
Åsberg Depression Rating Scale (MADRS). These assessments were performed prior to and 6 weeks after
non-standardized ECT.
Results:: Compared to baseline, the mean depression severity level was nearly halved and there were
significant improvements in mean levels of Speed of Processing, Attention/Vigilance, and Visual Learning
6 weeks after ECT. The other cognitive domains were not altered from baseline. There was no significant
change in subjective cognitive complaints. At baseline, there were several significant correlations be-
tween the MADRS and MCCB scores. There was no strong association between the EMQ and MCCB scores
at either assessment point, but the post-ECT EMQ score was significantly correlated with depression
severity.
Limitations: Major limitations were low N and lack of uniform ECT procedure.
Conclusions: There was significant improvement in Speed of Processing, Attention/Vigilance, and Visual
Learning 6 weeks after ECT. Cognitive tests scores were related to severity of depression, but not to
subjective memory complaints.

1. Introduction

Electroconvulsive therapy (ECT) is a life-saving intervention in
treatment-resistant depression, and often results in rapid symp-
tom relief. However, fear of memory loss is often cited as the main
reason for not consenting to this type of treatment (Fraser et al.,
2008). The precise nature, severity, and persistence of such side-
effects have been the subject of intense debate.

A meta-analysis found that a sizable minority of patients report
reduced cognitive function, mostly affecting speed of processing,
executive function, and episodic memory during the first week
after treatment (Semkovska and McLoughlin, 2010). However, 15
days after treatment, these functions were recovered or even im-
proved. In the largest and longest-lasting investigation to date, a

hn).

multi-center study of attention, learning, short-term memory, and
retrograde amnesia for biographical events in 260 patients, Sack-
eim et al. (2007) reported that most cognitive parameters were
significantly improved 6 months post ECT relative to pre ECT le-
vels. However, reaction time/speed of processing was still com-
promised at follow-up. Sustained adverse cognitive effects at fol-
low-up were associated with demographic factors such as ad-
vanced age, female gender, and lower baseline intellectual
function.

Methodological aspects of ECT may contribute to post-treat-
ment cognitive dysfunction. For this reason, sinus wave stimula-
tion is no longer recommended, as square pulses result in less
cognitive side-effects (Payne and Prudic, 2009). For the same
reason, unilateral electrode placement is preferred over bilateral
placement (Sackeim et al., 2000; 2007), although clinical char-
acteristics of the patient may overrule the attempt to minimize
cognitive side effects. Brief pulses usually have a stronger anti-
depressive effect compared to ultra-brief stimulation, and recent

www.sciencedirect.com/science/journal/01650327

www.elsevier.com/locate/jad

http://dx.doi.org/10.1016/j.jad.2016.03.062

http://crossmark.crossref.org/dialog/?doi=10.1016/j.jad.2016.03.062&domain=pdf

mailto:h.c.mohn@psykologi.uio.no

http://dx.doi.org/10.1016/j.jad.2016.03.062

Table 1.
Demographic characteristics of the participants (N¼31).

Age (years) 46.1 (SD 10.6)

Gender n¼10 (32.2%) men
n¼21 (67.7%) women

Education
Elementary school n¼9 (29.0%)
High school n¼12 (38.7%)
BA/BA þ n¼10 (32.2%)
Years since first onset of depression 20.6 (SD 11.2, range 5–40)

Age and Years since onset in mean.

C. Mohn, B.R. Rund / Journal of Affective Disorders 202 (2016) 10–15 11

research demonstrates no differences in cognitive side effects
between these two methods (Spaans et al., 2013; Verwijk et al.,
2015).

Lack of systematic monitoring has made it impossible to elu-
cidate the cognitive side effects of ECT with respect to precise
characteristics, severity, and duration (Rasmussen, 2015). There is
a large number of studies of cognitive effects of ECT, but they are
often limited by the small number of cognitive domains assessed
(e.g., Falconer et al., 2010; Porter et al., 2008). A recent post ECT
study investigated a broad range of cognitive functions employed
participants up to 82 years of age, risking contamination of the
results due to early stages of dementia (Bodnar et al., 2015). Thus,
there is a need for post ECT studies using comprehensive test
batteries assessing a broad range of cognitive functions in younger
samples.

The MATRICS Consensus Cognitive Battery (MCCB) (Nuechter-
lein and Green, 2006) consists of 10 tests assessing 7 cognitive
domains – Speed of Processing, Attention/Vigilance, Working
Memory, Verbal Learning, Visual Learning, Reasoning/Problem
Solving, and Social Cognition. The MCCB has very good psycho-
metric properties, and is well suited for use in a clinical setting
with severely ill respondents (Nuechterlein and Green, 2006). It
was developed for the schizophrenia population, but is also used
with bipolar disorder (Burdick et al., 2011; Kessler et al., 2014; Lee
et al., 2013; van Rheenen and Rossell, 2014), and major depressive
disorder (MDD) patients (Murrough et al., 2015). In a baseline
article from the current project, we have recently demonstrated
that the MCCB is able to separate cognitive functioning of MDD
patients and healthy controls, and that the scores of the depres-
sion group were generally significantly lower than those of the
control group (Mohn and Rund, 2016).

Although subjective complaints of cognitive impairments may
occur after ECT, these subjective reports are not necessarily sup-
ported by objective neuropsychological test results (Coleman et al.,
1996; Prudic et al., 2000). In general, there is a well-known dis-
crepancy between subjective cognitive complaints and objective
test performance, both in individuals suffering from mental illness
(Moritz et al., 2004) and healthy individuals (van der Elst et al.,
2008; Stenfors et al., 2014). We are aware of only one study of the
relationship between subjective memory report and neu-
ropsychological test scores (Brakemeier et al., 2011). That study
found a discrepancy between subjective and objective cognitive
function, but was limited by the low number of neuropsycholo-
gical tests employed.

In ill individuals, the above discrepancy may partly be ex-
plained by the severity of the depressive symptoms, as depression
intensity is correlated with subjective memory failure (Coleman
et al., 1996; Prudic et al., 2000). In this study, we will describe the
relationship between depression severity, subjective cognitive
complaints and MCCB performance.

As previous findings of cognitive changes after ECT are con-
flicting, no specific hypotheses were formulated. The following
research questions were asked: (1) Is there a change in cognitive
function, as assessed with a comprehensive test battery, 6 weeks
after ECT? (2) Are the cognitive test scores related to depression
severity and subjective memory complaints?

2. Method

This paper is the first follow-up report issued from a 2-year
longitudinal project on cognitive effects of ECT for major depres-
sion in South-Eastern Norway. We aim to monitor the cognitive
status of the participants at regular intervals, using a compre-
hensive neuropsychological test battery with good psychometric
properties. This first paper presents results from the first follow-

up assessment, 6 weeks after the ECT was completed.

2.1. Participants

Demographic data are presented in Table 1. The patient group
consisted of 31 White participants with a major depression dis-
order recruited from the ECT clinical sections at Vestre Viken
Hospital Trust and Vestfold Hospital Trust in South-Eastern Nor-
way. All patients set to undergo ECT and fulfilling the inclusion
criteria of the project were invited to participate. Two eligible
patients could not be tested for lack of time before the start of ECT,
while two others gave initial consent to project participation, but
changed their minds due to fatigue the day of testing. Finally, one
patient withdrew from the project due to confusion and lack of
motivation after completing the initial two subtests. The remain-
ing sample consists of 31 patients, who were included from March
2011 to November 2014.

Inclusion criteria were age above 18 and below 70 years, ca-
pacity for giving informed consent to both ECT and participation in
this project, ability to understand spoken and written Norwegian,
and a diagnosis of a treatment resistant major depressive episode.
The diagnosis of “treatment resistant depression” was made by the
clinicians based on previous lack of response to antidepressant
medication in combination with psychotherapy. Exclusion criteria
were ongoing alcohol or drug abuse, ongoing neurological illness,
and ECT within the last two years.

2.2. Clinical assessment

The diagnosis of a major depressive episode (F 32.1, F 32. 2, F
32.3) was established by clinical interviews by hospital staff ac-
cording to the ICD-10 criteria (WHO, 1993). Several different
clinicians were involved in the diagnostic process. The patients
were severely ill, and the decision to commence ECT was some-
times made so rapidly that the diagnostic process could not be
undertaken by one and the same clinician. We did, however, rely
on comprehensive information from the patients’ journals to
support the diagnosis made according to the ICD-10 system.

Severity of depression was assessed with the Montgomery-
Åsberg Depression Rating Scale (MADRS, Montgomery and Åsberg,
1979) at the start of the neuropsychological assessment session.
Twenty-three of the patients were diagnosed with recurrent uni-
polar depression (F 33) and 10 with bipolar disorder type II (F 31).
Seven had experienced psychotic symptoms during depressive
episodes, 9 had moderate anxiety symptoms, and 4 partially ful-
filled the criteria for a personality disorder (emotionally unstable
personality disorder, F 60.3, and anxious personality disorder, F
60.6). Five of the patients had been treated with 1–2 series of ECT
more than 2 years previously. All patients had discontinued their
psychotropic medication 1–7 days before baseline testing. Five
patients did not use any regular medication at baseline, and
6 were medicine free at 6 weeks follow-up. At both assessment
points, medication for anxiety and/or insomnia had been

Table 2.
Medication (CDD) before and 6 weeks after ECT (N¼31).

Pre ECT Post ECT

Antidepressants 2.5 2.4
Antipsychotics 1.1 1.3
Lithium .8 .8
Anticonvulsants .6 .2

CDD: Calculated dose of medication based on the prescribed dosage divided by the
defined daily dosage.

Table 3.
Raw scores of the MADRS, the MCCB tests, and EMQ before and 6 weeks after ECT
(N¼22–31).

Pre ECT Post ECT F η2

MADRS 33.4 (7.7) 17.7 (8.1) 60.17nnn .67
Speed of processing
TMT-A 49.6 (25.5) 39.7 (20.7) 6.01n .17
Symbol coding 40.4 (13.0) 44.9 (11.7) 8.74nn .23
Fluency 21.3 (8.4) 21.9 (6.3) .36 ns .01
Attention/Vigilance (CPT-IP)
(n¼22)

2.48 (0.5) 2.77 (0.4) 7.61n .29

Working memory
SS-WMS 12.9 (3.1) 13.6 (3.3) 2.34 ns .07
LNS 12.1 (3.9) 12.4 (3.7) .46 ns .02
Verbal learning (HVLT-R) 22.7 (5.9) 23.1 (6.0) .23 ns .01
Visual learning (BVMT-R) 21.2 (8.6) 23.3 (7.8) 7.32n .20
Reasoning/Problem solving
(Mazes)

12.3 (8.0) 13.6 (7.8) 2.53 ns .08

Social cognition (MSCEIT) (n¼27) 93.5 (8.9) 95.0 (10.3) .74 ns .03
EMQ 105.7 (37.6) 109.4 (43.1) .21 ns .01

Scores in mean (SD). F: Significance test of time differences.
ns: non significant. η2: effect size. Abbreviations: MADRS: Montgomery-Åsberg
Depression Rating Scale, TMT-A: Trail Making Test A, CPT-IP: Continuous Perfor-
mance Test-Identical Pairs, SS-WMS: Spatial Span-Wechsler Memory Scale, LNS:
Letter Number Span, HVLT-R: Hopkins Verbal Learning Test Revised, BVMT-R: Brief
Visuospatial Memory Test Revised, MSCEIT: Mayer-Salovey -Caruso Emotional In-
telligence Test, EMQ: Everyday Memory Questionnaire.

nnn po .001.
nn po .01.
n po .05.

C. Mohn, B.R. Rund / Journal of Affective Disorders 202 (2016) 10–1512

permitted the evening before. See Table 2 for information on the
daily defined doses of medication (WHO, 2010).

2.3. Electroconvulsive therapy

From a scientific point of view, the ECT procedure should be
uniform. However, the anti-depressive effect of ECT depends upon
patient characteristics as well as stimulus type and strength.
Therefore, it was considered unethical to refrain from providing
treatment at individually effective doses, and no uniform ECT
procedure was followed. Each treatment procedure was tailored to
the individual patient. All patients received square wave, brief
pulse (0.5 ms) stimulation from a Thymatron system machine 2
(n¼3) or 3 (n¼28) times a week. The stimulation was titrated
according to the individual’s seizure threshold. Mean number of
applications per ECT series was 11.9 (SD 4.1, range 6–23). Right
unilateral electrode placement was used in 23 cases, bifrontal
placement in 1 case, and mixed placement (switching from right
unilateral to bifrontal in mid-series) in 7 cases. Anesthetic agents
were alfentanil, propofol, or thiopental. Succinylcholine was used
as a muscle relaxant. These pharmacological agents were ad-
ministered in dosages according to the physical characteristics of
each individual participant.

After this first series, 7 patients received maintenance treat-
ment with a mean 9.9 of applications (SD 6.7, range 1–18). Among
these, 5 had right unilateral, 1 bifrontal, and 1 mixed electrode
placement.

The participants were cognitively assessed 1–3 days before the
start of ECT and 6 weeks after completion of ECT. For the 7 patients
who received maintenance treatment, the follow-up cognitive
assessment was performed 6 weeks after the final application of
maintenance ECT.

At baseline, 36 patients were originally assessed. At follow-up
6 weeks later, 31 of them were available for testing, resulting in a
drop-out rate of 14%. The reasons for dropping out were the fol-
lowing: extended travelling/vacation (n¼2), lethal physical illness,
unrelated to ECT or other depression treatment, requiring hospi-
talization (n¼1), a depression level too severe to participate in
testing (n¼1), and refusing further contact with tertiary health
care (n¼1).

All participants signed an informed consent form before both
testing sessions. These consents were given in addition to their
consenting to ECT treatment, which was obtained by the clinical
departments. The study was approved by the Regional Committee
for Research Ethics for Health Region South-East (REK Sør-Øst).

2.4. Neuropsychological assessment

The cognitive assessment was carried out by a clinical psy-
chologist with extensive neuropsychological training (CM). The
participants were tested at their respective clinical wards.

The MCCB covers 7 cognitive domains using 10 subtests
(Nuechterlein and Green, 2006; 2009):

Speed of Processing, consisting of the subtests Trail Making Test
A (TMT-A; United States War Department, 1944), Symbol Coding

(Brief Assessment of Cognition in Schizophrenia, BACS; Keefe,
1999), and Fluency (Category Fluency; Blair and Spreen, 1989),

Attention/Vigilance, assessed by The Continuous Performance
Test-Identical Pairs (CPT-IP; Cornblatt et al., 1988),

Working Memory, consisting of the subtests Spatial Span (The
Wechsler Memory Scale, SS-WMS; Wechsler, 1997) and Letter
Number Span (The University of Maryland Letter Number Span
test, LNS; Gold et al., 1997),

Verbal Learning, assessed by the revised Hopkins Verbal
Learning Test (HVLT-R, immediate recall; Brandt and Benedict,
2001),

Visual Learning, measured by the revised Brief Visuospatial
Memory Test (BVMT-R; Benedict, 1997),

Reasoning/Problem Solving, assessed by the Mazes test (Neu-
ropsychological Assessment Battery, NAB; White and Stern, 2003),
and Social Cognition, measured by the Managing Emotions part of
the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT;
Mayer et al., 2002).

For a detailed description of the tests, see Mohn et al. (2012).
The average time of completion of the MCCB is 45–60 min Due to
excessive fatigue, 4 patients did not perform the MSCEIT test and
9 did not perform the CPT-IP test. This is indicated in Tables 3 and
4.

Norwegian T scores have been published for the 20–59 years
age group (Mohn et al., 2012). As the current study includes par-
ticipants above 60 years, the MCCB results are presented in raw
scores.

After the completion of the MCCB, the patients filled in the
Everyday Memory Questionnaire (EMQ, Sunderland et al., 1983),
assessing practical attention and memory functions in 28 items.

2.5. Statistics

All statistical analyses were performed with IBM SpSS Statistics
version 22. Time differences in neurocognitive function were
analyzed with repeated-measures ANOVAs with effect sizes re-
ported as partial eta squared (η2). The relationships between the

Table 4.
Pearson’s correlations of the relationship between subjective cognitive complaints (EMQ) and MCCB test scores before and 6 weeks after ECT (N¼22–31).

TMT-A BACS Fluency CPT-IP

SS-WMS LNS HVLT-R BVMT-R Mazes MSCEIT

Pre ECT
EMQ � .04 � .07 � .18 .29 .08 .02 .04 .28 .10 .34
Post ECT
EMQ .35 � .32 � .29 .10 � .47n � .29 � .55nn � .22 � .26 � .27

nn po .01.
n po .05 (2-tailed).

C. Mohn, B.R. Rund / Journal of Affective Disorders 202 (2016) 10–15 13

EMQ score, the MADRS score, and the MCCB scores were in-
vestigated with Pearson’s correlations.

3. Results

The MADRS score was nearly halved post treatment, indicative
of significant clinical effect of ECT (Table 3). There was no statis-
tically significant change in the EMQ score (Table 3). Compared to
baseline, tests assessing Speed of Processing, Attention/Vigilance,
and Visual Learning showed significantly improved function after
ECT, and the effect sizes were large (Table 3).

At baseline, there were no significant associations between
subjective memory complaints (EMQ) and the cognitive test
scores. After ECT, there were two such negative significant corre-
lations, with Spatial Span and Verbal Learning (Table 4). This in-
dicates a weak relationship between subjective and objective
cognitive function assessments post treatment.

The relationship between the MADRS score and the cognitive
function scores was strong at baseline, with 7 correlations reach-
ing statistical significance. After ECT, only two correlations were
significant – the EMQ and Verbal Learning (Table 5). Hence, sub-
jective memory complaints after ECT seem related to depression
severity and not to actual cognitive impairment, as measured with
standard neuropsychological tests.

4. Discussion

Compared to the baseline assessment, our participants with
major depressive disorder exhibited significantly improved cog-
nitive function 6 weeks after cessation of ECT. The affected do-
mains were Speed of Processing, Attention/Vigilance, and Visual
Learning. No other MCCB scores were altered from baseline.
Moreover, the cognitive test scores were strongly related to de-
pression levels, but not to subjective memory complaints.

Our results correspond to the findings of the meta-analysis of
Semkovska and McLoughlin (2010), who reported overall im-
proved cognitive function 2 weeks after ECT. Moreover, in another
Norwegian MCCB study, Kessler et al. (2014) found increased
cognitive performance in bipolar disorder patients 3 weeks after

Table 5.
Pearson’s correlations of the relationship between depression severity (MADRS) and cog
31).

EMQ TMT-A BACS Fluency CPT-IP

Pre ECT
MADRS � .25 .31 � .47nn � .47nn � .07
Post ECT
MADRS .59nn .14 � .24 � .20 .24

nn po .01.
n po .05 (2-tailed).

ECT, and no cognitive differences between patients treated with
ECT and with anti-depressive medication. Ours is the first study
documenting cognitive improvement after ECT in MDD patients
using the comprehensive, standardized, and psychometrically
strong MCCB assessment procedure.

The large post-ECT changes in Speed of Processing, Attention/
Vigilance, and Visual Learning is concordant with several studies
reporting these domains to be strongly affected by depression
(Egeland et al., 2003; Halvorsen et al., 2012; Lee et al., 2012;
Murrough et al., 2015; Rund et al., 2006; Trivedi and Greer, 2014).
Moreover, the same patients exhibited impaired levels of the same
domains at baseline (Mohn and Rund, 2016). As the depression
level is reduced, performance of these tests is likely to improve
accordingly. As 9 of our participants did not perform the CPT-IP
test, there is some uncertainty regarding the Attention/Vigilance
finding in our study.

Improved Speed of Processing after ECT has been noted by
others (Tsourtos et al., 2007). However, in the Sackeim et al.
(2007), speed was still impaired 6 months after ECT. Possibly,
methodological differences in terms of patient characteristics,
technical aspects of ECT application, and cognitive assessment may
explain these divergent results.

Our finding of improved Visual Learning is in accordance with
the results of Bodnar et al. (2015) 3 months after ECT, and Maric
et al. (2015) 1 month after ECT. However, Falconer et al. (2010)
reported visuospatial decrements 1 month after ECT. Again, pa-
tient characteristics and methodological aspects may be relevant
explanations.

Retrograde amnesia for personal events is one of the most
consistently reported side effects of ECT (Fraser et al., 2008). We
did not assess this function. The main reasons were the wish to
spare a severely ill and fatigued group of participants another time
consuming test, and lack of psychometrically strong assessment
tools of retrograde cognitive function in depressed individuals
(Söderlund et al., 2014). Retrograde cognitive function may be
impaired in patients who have been treated with ECT even in the
face of unimpaired or improved anterograde function (Coleman
et al., 1996; Kessler et al., 2014; Prudic et al., 2000). Therefore,
cannot conclude that our participants did not display any cognitive
side effects of ECT.

There was a strong relationship between depression severity
and cognitive function at baseline, but not 6 weeks after ECT. This

nitive variables (EMQ and MCCB test scores) before and 6 weeks after ECT (N¼22–

SS-WMS LNS HVLT-R BVMT-R Mazes MSCEIT

� .38n � .60nn � .53nn � .43n � .28 � .44n

� .26 � .28 � .42n � .02 � .05 � .32

C. Mohn, B.R. Rund / Journal of Affective Disorders 202 (2016) 10–1514

is probably explained by the significant reduction in depression
symptoms after treatment. However, the significant correlation
between the MADRS score and the EMQ score at this time point is
interesting, as it is supported by a similar finding by Brakemeier
et al. (2011). In combination with our report of no strong relation
between subjective (EMQ) and objective (MCCB) cognitive func-
tion, we suggest that the memory complaints often reported by
depression patients after ECT is related to the level of depression
and not to actual cognitive performance.

4.1. Limitations and strengths

The first major limitation is the relatively small sample. Con-
sequently, we were not able to compare the patients with MDD
alone to those with symptoms of bipolar disorder II or psychosis,
or to analyze gender effects. However, our heterogeneous patient
group is a typical naturalistic sample, and our findings are prob-
ably clinically valid. Nevertheless, some of the statistical results
with small effect sizes should be interpreted with caution.

Second, the ECT procedure was not uniform, but tailored to
meet each individual patient’s clinical needs. Again, however, this
renders our sample naturalistic and clinically valid.

Third, the MCCB was originally developed for assessment of
schizophrenia patients, and has not been validated for other clin-
ical populations. However, it is increasingly used in depression
research (Kessler et al., 2014; Murrough et al., 2015), and in a
baseline study of the present patients, this battery was able to
differentiate between the depression group and the healthy con-
trol group (Mohn and Rund, 2016). Cleary, this battery may be
employed in depressive disorder populations, although formal
validation studies from these patient groups are still lacking.

Fourth, it may be argued that the relatively short time span
between baseline and follow-up cognitive assessment facilitates
learning effects. However, one of the explicit aims behind the
MCCB test selection and standardization procedure was the de-
velopment of a battery that allows repeated assessments at rela-
tively short intervals, and alternate forms of the tests are used
when appropriate (Nuechterlein et al., 2008). Moreover, other re-
levant studies have employed shorter follow-up periods than ours,
with no reports of practice effects (Murrough et al., 2015; Rose-
berry and Hill, 2014).

The major strengths of this study are the low drop-out rate and
the use of a comprehensive, internationally validated neurocog-
nitive test battery with strong psychometric properties in combi-
nation with subjective reports of memory complaints.

5. Conclusion

Six weeks after ECT, cognitive function was either significantly
improved or unaltered from baseline in MDD patients. Depression
severity was associated with cognitive test scores at baseline, but
not at follow-up. There was a discrepancy between cognitive test
scores and subjective report of memory problems, and the latter
were related to depression severity. The clinical implication is that
complaints of cognitive problems after ECT could be the result of
the depressive illness and not a side effect of ECT.

Conflict of interest
No conflict of interest declared.

Role of funding source
This study was supported by grants to Dr. Rund (no. 2009044 and no. 2011/125)

from the Helse Sør-Øst (Health South East) Regional Hospital Trust and Vestre
Viken Hospital Trust. The funding source has not contributed to the performance of

the study or preparation of this article.

Contributors

Dr. Mohn designed the study, performed the neurocognitive
assessments and the statistical analyses, and drafted the paper. Dr.
Rund participated in the design of the study, the interpretation of
the results, and in the drafting of the paper.

Acknowledgements
Hilde Jakobsen, RN, Gro Liebeck, RN, and Drs Jovan Randjelovic, John E. Berg,

Phelix Blayvas, and Arne Thorvik are gratefully acknowledged for recruiting the
patients for this study. Statistical advice was provided by Ms. Cathrine Brunborg,
Oslo University Hospital.

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Significantly improved neurocognitive function in major depressive disorders 6 weeks after ECT

Introduction
Method
Participants
Clinical assessment
Electroconvulsive therapy
Neuropsychological assessment
Statistics
Results
Discussion
Limitations and strengths
Conclusion
Conflict of interest
Role of funding source
Contributors
Acknowledgements
References

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