Improvement of persistent impairments in Executive Functions and Attention following Electroconvulsive therapy in a case control longitudinal follow up study

Improvement of persistent impairments in Executive Functions and Attention following Electroconvulsive therapy in a case control longitudinal follow up study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Improvement of persistent impairments in Executive Functions and Attention following Electroconvulsive therapy in a case control longitudinal follow up study Åsa Hammar, Eivind Haga Ronold, Alden Spurkeland, Rita Ueland, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5019584/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 20 Nov, 2024 Read the published version in BMC Psychiatry → Version 1 posted 10 You are reading this latest preprint version Abstract Background How cognition is influenced by electroconvulsive treatment (ECT) and major depressive disorder (MDD) is still debated. The development and etiology of neurocognitive impairment in MDD was examined by investigating the cognitive profile following ECT related to the state-, scar and trait-perspectives, with the former predicting improvements parallel with depressive symptoms, while the two latter expected persisting impairments. executive functions (EF) and attention are central to cognition and alterations in these functions could influence other domains like memory. The main aims of the present study were to examine short- and long-term effects of ECT on EF and attention in patients with major depressive disorder by exploiting the rapid antidepressant effect of this treatment. Methods A case-control longitudinal follow-up design was used to investigate the effects of unilateral brief-pulse ECT on EF and attention in patients with depression ( n = 36) compared to untreated healthy controls ( n = 16). EF and attention were measured pre-treatment (T1), approximately three weeks (T2) and 6 months post-treatment (T3). Results The patient group showed significantly worse performance on most tests compared to healthy controls pre-treatment, and no short- or long-term worsening of EF and attention following ECT was found. Significant improvement was identified in patients’ attentional capacity, processing speed and inhibition after ECT. Conclusions The present study showed that there was no cognitive worsening after ECT treatment. An improvement in several of the tests measuring inhibition, attention and processing speed was parallel to symptom reduction, with the former showing associations to symptom change, suggesting state-related effects from improved mood. Still, the patient group performed significantly worse on most measures both pre-treatment and at the short- and long- term follow-ups, indicating prevailing trait or scar effects on cognitive functions and potential lack of practice effects. Clinical trial number: Not applicable. ECT short- long-term effects longitudinal iatrogenic effects EF cognitive function attention Treatment-resistant Depression MDD Background Depression is one of the leading causes of disability worldwide and largely contributes to the global burden of disease( 1 ), through substantial functional impairment( 2 , 3 ). Although there are effective treatments targeting depression, over one third of patients do not respond to first line interventions and could be considered treatment-resistant( 4 ). Electroconvulsive therapy (ECT) represents one of the most effective treatments of severe and depression( 5 – 8 ), with high remission rates even in cases of treatment-resistant depression( 1 , 4 , 9 ). However, ECT is often used as a treatment of last resort( 10 , 11 ), possibly due to stigma( 12 , 13 ), and concerns about adverse side effects( 14 ). Despite accumulating evidence of its safety and effectiveness, it is still unclear to what degree ECT can cause persistent neurocognitive deficits in some patients treated for depression( 13 ). Enhanced knowledge about possible short- and long-term side-effects of ECT is considered crucial for improving clinicians and patients’ ability to make informed decisions about treatment. Major Depressive Disorder (MDD) is associated with cognitive impairments( 15 – 18 ), in remission and worsening with the duration of depressive episodes( 15 , 16 ). Different perspectives exist regarding the etiological nature of neurocognitive impairment in MDD. These vary regarding the view on impairments could be either a pre-existing vulnerability (trait) or related to the depressive symptom load (state), or a consequence of progressive scarring due to neurotoxic effects of depression (scar)( 17 , 18 ). There is some support in the literature for all three perspectives( 18 ), and examining changes in different domains of cognition following the rapid ECT-treatment effect of depression could inform on these perspectives. Executive functions (EF) and attention are two of the neurocognitive domains significantly affected in patients suffering from depression( 19 – 21 ), with impairments still evident in remission( 16 ). EF are needed to manage most of our daily activities and underlie our ability to organize thinking( 17 , 22 ), self-regulate, plan, inhibit and make decisions( 23 ). When EF is measured objectively with standardized neuropsychological tests, people with MDD tend to perform significantly worse compared to healthy controls on tasks measuring aspects of EF such as shifting, inhibition and verbal fluency in the acute state of depression( 21 , 23 , 24 ), persisting beyond the depressive episode( 16 , 24 – 26 ). These findings indicate a possible trait- or scarring effect of depression on EF, however the research is inconclusive regarding which aspects of EF are affected by scarring( 18 ), or by ECT( 13 ). Measuring different aspects of EF pre- post ECT could inform on this. Similar to EF, attention is an associated multidimensional construct and a selection mechanism( 27 ), that allows control of limited cognitive resources in a flexible manner( 28 ), and is closely related to processing speed( 29 ). There is support in the literature for attentional deficits during the acute state of depression, although findings are inconsistent regarding which aspects of the attentional domain that are affected( 30 – 32 ). In addition, there are findings indicating that the severity of depressive symptoms could influence the extent of impairment( 30 ). Although attentional deficits are shown to persist in remission( 16 , 18 ), they are smaller compared to the acute state( 13 , 31 , 32 ). In line with this, recent studies suggest that attentional functioning improves following treatment( 15 , 33 ), indicating a possible state-effect of depressive symptoms on attention. However, various aspects of attention could be influenced differently, and patient group characteristics, such as severity of depression and duration is related to both improvement and impairment( 15 , 32 , 34 – 36 ). Investigating aspects of attention pre- post ECT could provide insight on the relationship between attention and depressive symptoms and severity, as well as the impact of ECT. Research on depressed patients treated with ECT indicate no lasting treatment induced deficits in objective measures of EF and attention( 9 , 37 – 41 ). However, an acute decline in attention and the executive aspect of inhibition was observed at the initiation of ECT-treatment but normalized after completion of treatment sessions( 42 ). Small decreases have been reported in verbal fluency shortly after ECT in heterogeneous patient samples( 13 ). Small to medium improvements have been reported for shifting, inhibition and planning, and recovery of baseline levels for verbal fluency in long-term measures post ECT( 13 , 37 ). Attentional functioning is shown to improve both short- and long-term post ECT-treatment( 13 , 39 , 40 ), particularly in the aspects of processing speed and working memory( 7 , 39 , 40 , 42 ). However, executive and attentional functioning in patients is still not comparable to healthy controls post ECT( 13 , 42 ), making it difficult to draw conclusions regarding the effects of ECT versus the effects of depression in relation to the state, trait and scar hypotheses. Importantly, there are several methodological shortcomings concerning previous research examining the effects of ECT on cognition that constrains the state of knowledge( 13 , 43 ). Firstly, there are few studies investigating longitudinal effects of ECT on cognition ( 13 , 40 , 43 ). Previous studies also lack inclusion of a healthy control group, which challenge controlling for practice effects due to repeated testing( 9 , 42 ). Studies also vary regarding how ECT as an intervention is applied, the timing of measurements and neuropsychological assessments( 13 ). In addition, both EF and attention could influence other cognitive functions like memory( 32 , 44 ), and thus the development of these functions following treatment is important for separating the cognitive residual symptoms related to depression history from side effects reported following ECT. Lastly, results from the same neuropsychological tests are being reported and interpreted differently, partly due to assumptions that the same tests are tapping multiple cognitive processes( 23 , 29 ). In the present study, these issues are reduced by including several outcome measures from both the executive and attentional domain. Prior research has faced challenges in effectively differentiating the effects of depression and ECT on cognitive functioning. This is rectified in the present study by including baseline measures and a healthy control group, to examine whether side-effects identified post ECT are treatment-induced, or if findings coincide with research demonstrating long-term cognitive impairment following severe depression( 16 , 18 , 24 – 26 , 43 ). In addition, by utilizing the rapid antidepressant effect of ECT( 7 , 43 ), our design allows for innovative exploration of the scar, trait and state perspectives in relation to the domains of executive and attentional functioning. While the state perspective would predict recovery of cognitive functions following ECT-treatment and symptom relief, the trait and scar perspectives would predict preexisting, lasting neurocognitive deficits, and even exacerbation of cognitive functions. Including a variety of measures and separating the domains of EF and attention enables identifying potential domain and aspect specific profiles. Objectives and Main Aim The main aim of this study is to investigate short- and long-term effects of ECT on objective and standardized tests of both executive and attentional functioning in patients with major depression. By using a healthy control group for comparison, the study estimates both changes within groups but also compares whether the patient group reaches a level of cognitive functioning that corresponds to healthy controls and differs in change compared to controls. Lastly, we aim to investigate the cognitive profile following ECT related to the state-, scar and trait-perspectives, and if these profiles are domain- or aspect-specific. Since the design will not allow a differentiation of whether persistent deficits are related to trait vulnerability or scarring, these two perspectives will be compared to the state perspective. The following research questions were formulated: Research questions Do patients suffering from depression have reduced executive functions and attentional capacity when compared to healthy controls pre ECT? Do patients´ executive and attentional functions improve shortly and long-termly (6 months) post ECT? Are patients' executive and attentional abilities comparable to healthy controls shortly post ECT and at 6 month follow up? Will the cognitive profile following ECT show improvement in EF and attention related to mood symptoms (state) or show pre-post persistent impairments (trait or scar)? Hypotheses Based on the previous literature regarding cognitive impairments in depression, we expect patients with MDD to have significantly poorer performance on all tests measuring attention and EF at baseline compared to healthy controls. Compared to baseline, patients' performances are expected to either improve or remain stable shortly post-treatment. As some findings indicate short-term declines in verbal fluency, while others show normalization to baseline levels, it remains unclear whether to expect a transient decline or baseline levels for verbal fluency shortly post-treatment. At six-month follow-up, we expect patients’ performance on all tests to either improve or return to baseline level. Specifically, we expect long-term improvement in the aspects of processing speed and working memory. However, we still expect patients to perform significantly worse compared to healthy controls. It is therefore expected that we will find both state-related function improvement, but also lasting impairment that is in line with trait- or scar-related effects of depression. Finally, we expect a significant improvement in depressive symptom load following ECT. Methods Study Design A pre-post intervention longitudinal follow up study was conducted (Oltedal et al., 2015), and data were collected at baseline prior to receiving ECT (T1), approximately 2 weeks post-treatment (T2) and 6 months post-treatment (T3). Patients were compared to a healthy control group that underwent repeated neuropsychological testing at the same time points as the patients. Clinical trial number: not applicable. Participants The original patient group consisted of forty (n = 40) participants who were referred to Haukeland University Hospital, Bergen, Norway, for ECT. Eligibility criteria included patients over the age of 18, with no upper age limit for participation, referred to ECT due to a moderate or severe depressive episode according to guidelines from Norwegian Health Department (2017). This usually entails lack of effect from conventional treatments and/or life-threatening depression. All patients fulfilled the criteria for one of the following ICD-10 diagnoses: F31.3 (10,3%) and F31.4 (7,69%); F32.1 (2,56%) and F32.3 (5,13%); F33.1 (12,32%) and F33.2 (56,41%) and F33.3 (5,13%). To be included, patients had to score 25 or higher on Montgomery Aasberg Depression Rating Scale (MADRS). Patients with both bipolar and unipolar depression were included. Exclusion criteria were pregnancy, an intelligence quotient (IQ) of ≤ 70 and a history of receiving ECT within the last 12 months. One patient was excluded due to an IQ score under 70. Twenty-six (n = 26) patients underwent neuropsychological testing at T1. Twenty (n = 20) patients returned for testing at short-term follow up (T2), with a late inclusion of ten (n = 10) patients, resulting in a total of thirty patients measured at T2 (n = 30). A total of nineteen (n = 19) patients returned for 6-month follow up (T3). The control group consisted of sixteen (n = 16) healthy controls of equivalent mean age and sex distribution as patients. Fifteen (n = 15) participants from the control group were assessed with the neuropsychological testing at T1, sixteen (n = 16) were assessed at T2, and fifteen (n = 15) participants returned for 6 months follow-up. Details on participant demographics are listed in Table 1 . Table 1 Demographics at Baseline for all Participants and Attrition Patients Patients (n = 36) Controls (n = 16) Attrition Patients Variable Mean SD Mean SD Mean T2 (n = 5) Mean T3 (n = 12) Age 45.06 14.21 42.06 16.23 42.2 40.42 Male/female 18/18 NA 5/10 NA NA NA Education 13.75* 3.32 16.31* 2.22 10.8** 13.5 Total IQ 106.22* 13.09 120* 7.17 97.6 110 MADRS T1 33.54* 5.26 1.92* 2.29 30.2 34.33 MADRS T2 15.08* 8.88 1.08* 1.44 MADRS T3 14.5* 11.06 0.77* 1.42 MADRS, Montgomery Aasberg Depression Rating Scale; NA, not applicable. *Means that are significantly different between groups with p < 0.01. Attrition: ** Means on variables where drop-out participants are significantly different (p < 0.05). ECT Treatment Stimulus and Electrode Placement Patients received three sessions with ECT per week until remission, or until the maximum of 18 sessions was reached. Patients underwent right unilateral electrode placements with a Thymatron System IV (Somatics LLC, Lake Bluff, Illinois) providing brief-pulse, square wave, constant current. Stimulus The initial stimulus energy was calculated based on gender and age, and the duration of the stimulus pulse was set to 0.5 ms. Anesthesia Thiopental or Propofol was given as anesthesia. Patients were hyperoxygenated with oxygen-enriched air, minutes before and during anesthesia to optimize the induction of seizures. Seizure Adequacy The adequacy of each seizure was evaluated by an ECT-clinician based on duration, reorientation time, clinical effect, and d-waves. Seizures that were evaluated by the ECT-clinician as not effective led to restimulation in the same session, and/or adjustment of the stimulus parameter in the following session. For specific information about the ECT treatment, see( 45 ). Clinical Measures The severity of the current depressive episode was verified and monitored by the MADRS scale( 46 ) at T1, T2 and T3. Neurocognitive Assessment Neuropsychological tests were administered by a trained technician and consisted of standardized tests measuring attentional resources and executive functions. Wechsler Abbreviated Scales of Intelligence( 47 ) was administered as estimate of general abilities (IQ). Executive Functioning Four tests from the Delis-Kaplan Executive Function System (D-KEFS( 48 )) were administered to measure aspects of executive functioning, with seven outcome variables included in analysis. In addition, the Wisconsin Card Sorting Test (WCST( 49 )) and the Continuous Performance Test-II (CPT( 50 )) were included. Inhibition was measured using the Color-Word Interference Test (CWIT). In the third condition of CWIT, measuring inhibition, participants are expected to identify the color ink of the word and suppress the response to read the word. In addition to this, the number of commissions on CPT was used as an estimate of inhibition ability. The number of commission errors is the number of times participants incorrectly press the key when seeing “X”. High scores correspond to poor performance in the inhibition tasks. Mental Flexibility or Shifting was measured using the fourth condition of CWIT, inhibition/switching, where participants are asked to switch from color naming of an incongruent word (CWIT 3) to reading (CWIT 2) when the word appears within a frame. In this task, high scores correspond to poor performance. In addition, the Category Switching condition of the Verbal Fluency test was included to measure flexibility and shifting. Category switching measures participants' ability to alternate between naming members of different categories, where higher scores equal better performance. Shifting was also measured using the number-letter switching condition of the D-KEFS Trail Making Test Part 4 (similar to TMT-B). In TMT- 4 participants have to shift between connecting letters and numbers, measured as time to complete the task. Therefore, higher scores correspond to poorer performance. In the WCST participants are asked to sort cards by different dimensions, such as color or shape, which demands maintaining or switching of rules in response to feedback. The number of successful switches between category sets and perseverative errors, which is applying an older previous rule for sorting, was used as an estimate for shifting ability. A high score on the WCST perseverative errors would indicate poor performance, while the contrary is true for WCST categories completed. Verbal Fluency was measured using D-KEFS Verbal Fluency Test consisting of the conditions: Letter Fluency and Category Fluency. Letter fluency is measured by asking patients to generate as many words as possible starting with a certain letter, while semantic verbal fluency is naming as many words as possible from a semantic category. In both measures of verbal fluency, higher scores equal good performance. Planning ability was measured using the Total Achievement Score of the Tower Test. Using as few moves as possible, the task of the D-KEFS Tower Test is to reproduce a pictured tower model, following a set of rules. For the Tower Test, higher scores indicate greater performance. Attentional functioning Four tests were administered to measure aspects of attentional resources; Digit Symbol Substitution Test (DSST( 47 )) Digit Span Test (DST( 47 )), omission errors in CPT and failure to maintain set in WCST. Auditory Attention and Working Memory were measured with DST. A sequence of numbers is read aloud to participants, who are then asked to repeat the sequence in the same (attention) or backward (working memory) order as presented. The number sequences get progressively longer. Low scores on DST equals poor performance. Visual Attention and Processing Speed were measured with the DSST. Participants are asked to match symbols to numbers according to a template. Within a given time frame, participants copy the symbols into empty spaces below a row of numbers. The number of correct symbols within the time frame constitutes the score, where low scores equaled poor performance. Inattention was measured with omission errors in CPT and failure to maintain set in WCST. In CPT participants are asked to press a key every time a letter appears on a computer screen, except for the letter “X”. Failure to press the key when a letter is displayed is an omission error and indicates inattentiveness or a lack of sustained attention. Failure to maintain set in the WCST is measured by the number of times a participant incorrectly changes their sorting strategy after the rule is known and before change is appropriate. High scores equal poor performance in both inattention tasks. Ethics Written informed consent from participants was collected in advance of participation. The study was approved by the Regional Committee for Medical and Health Research Ethics South East, ID: 2013/1032 ECT and neurology. Statistics, Contrast- and Change Scores All statistical analyses were performed in IBM SPSS Statistics version 28 (IBM Corp, Armonk, New York). One-way ANOVA tests were performed to assess differences between groups in demographic variables, symptomatology, results on neuropsychological tests at all time points, attrition effects from the patients that dropped out, and differences between change scores. A one-way between-group ANOVA was conducted to explore the impact of ECT on EF and attention in patients with MDD. Outcome measures were assessed for normality and Mann-Whitney U-tests were used as a nonparametric alternative to examine group differences in performance on three outcome variables of the WCST (preservative errors, failure to maintain set, categories completed) and on CPT omissions, and Lenhard et al. ( 51 ) was used to calculate eta squared for these tests. All variables consisted of raw scores, except for CPT where t-scores were used. Dependent samples t-test were done to assess changes in cognitive functioning. A paired-samples t-test was conducted to evaluate the impact of ECT on EF and attentional functioning in patients with major depression. Paired-samples t-tests were also conducted on means for the control group to detect retest/practice effects. Results are not corrected for multiple comparisons, as conducting a Bonferroni correction would result in low power to detect significant findings due to the small sample size and drop-out rates in the study. Contrast scores for investigating EF relatively independent from processing speed( 26 ), were calculated by the following formulas: Inhibition contrast = CWIT 3 – (CWIT 1 + CWIT 2)/2, Mental/flexibility contrast = CWIT 4 – (CWIT 1 + CWIT 2 + CWIT 3)/3, Shifting contrast = TMT 4 – (TMT 1 + TMT 2 + TMT 3 + TMT 5)/4. Change scores were calculated subtracting follow up test results and MADRS scores from baseline so that positive values indicated improvements( 52 ). Bivariate correlation coefficients were calculated for change scores in neuropsychological tests and depressive symptoms. Significance level was set at p = .05. Effect sizes were described as small, medium and large according to Cohen ( 53 ). Results Demographic variables, clinical measures and attrition effects One-way ANOVA revealed that the patient group had a significantly lower IQ and had fewer years of education in comparison with the control group (See Table 1 ). Regarding attrition effects, patients lost to follow-up from T1 to T2 had significantly fewer years of education compared with participating patients. There were no significant differences in any of the other demographic variables for patients lost to follow-up. Table 2 Differences between groups at T1, T2 and T3 Time Pre-ECT (T1) Post-ECT (T2) 6-month (T3) Groups n (male/female) Patients n = 26 (18/18) Control n = 15 (5/10) Statistics Patients n = 30 Control n = 16 Statistics Patients n = 19 Control n = 15 Statistics Outcome variable M(SD) /Mr M(SD) /Mr F(df) /U p Eta sq. M(SD) /Mr M(SD) /Mr F (1) /U p Eta sq. M(SD) /Mr M(SD) /Mr F (1) /U p Eta sq. EF CWIT-3 Inhibition 70* (28.4) 49.8* (9.1) 7.1 (1,38) .011 .157 67.8* (27.5) 47.8* (9.1) 8.289 (1, 44) .006 .159 66.3* (29.7) 49* (9.7) 4.672 (1,32) .038 .127 CWIT-3 Contrast scores 38.9* (23.1) 23.4* (6.1) 6.5 .015 .146 36.6* (22.7) 21.4* (6.2) 6.811 .012 .134 36.42 (25.81) 23.27 (8.44) 3.572 .068 .100 CWIT-4 Inhibition/switching 73.2 (28.3) 58.7(13.1) 3.501 .069 .084 78.8* (32) 55.2* (11.7) 8.07 .007 .155 70.11* (30.75) 51.93* (10.08) 4.802 .036 .13 CWIT4 Contrast scores 29.2 (17.5) 24.4 (9.2) .947 .337 .024 35.3* (22.9) 22.1* (8) 5.002 .03 .102 28.07 (20.9) 18.44 (8.29) 2.817 .103 .081 Letter Fluency 39.9 (11.1) 46.4 (12.1) 3.026 .090 .074 36.6* (12.3) 49.6* (13.3) 10.764 .002 .2 33.9* (11.21) 53.47* (13.47) 21.391 < .001 .401 Category Fluency 41* (8.4) 52.7* (10.1) 15.663 < .001 .292 40.2* (9.5) 52.2* (9) 17.020 < .001 .284 38.11* (8.01) 51.4* (9.16) 20.353 < .001 .389 Category Switching 13.8 (2.7) 14.7 (3.4) .784 .382 .020 12.55* (2.76) 14.4* (2.6) 4.68 .036 .098 12.16* (2.36) 15.53* (2.47) 16.408 < .001 .339 TMT-4 100.3* (42.5) 61.6* (19.1) 10.978 .002 .229 100.8* (47) 63.1* (27.4) 8.606 .005 .167 100.22* (46.06) 65.87* (26.04) 6.57 .015 .175 TMT-4 Contrast scores 76.7* (37.7) 44.3* (17.9) 9.641 .004 .207 77.2* (40.2) 45.9* (23.5) 8.141 .007 .159 76.07* (38.19) 49.11* (21.78) 5.866 .021 .159 Tower Total Achievement 16.9* (3.3) 20.1* (3.7) 8.226 .007 .178 17.6* (3.3) 20.8* (3.1) 9.482 .004 .184 17.78* (4.32) 22.8* (4.16) 11.434 .002 .269 CPT Commissions (t-scores) 55.9 (13.4) 50.2 (10) 1.981 .167 .05 49.6 (11.1) 44.5 (7.5) 2.744 .105 .06 51.48* (9.54) 43.41* (6.21) 7.801 .009 .206 WCST Categories Completed 19.96 21.4 201 .72 0.004 22.69 23.56 241 .666 0.001 16.19 17.97 149.5 .606 0.008 WCST Perseverative Errors 23 16.33 125 .083 0.076 26.72 16.25 124 .01 0.146 20.92 12.3 64.5 .009 0.197 Attention DST 12.04* (2.14) 13.93* (2.93) 5.64 .022 .126 12.65 (2.56) 13.37 (2.68) .78 .380 .018 12.84 (2.65) 14.06 (3.86) 1.19 .282 .036 DSST 43.31* (14.38) 59,93* (11.68) 14.47 < .001 .271 44.58* (17.68) 63.62* (14.64) 13.42 < .001 .238 46.21* (14.69) 65.20* (12.20) 16.19 < .001 .336 CPT omission (t-scores) 23.86 14.90 103.5 .018 .138 25.74 18.03 152.5 .059 .079 19.56 13.03 75.5 .049 .12 WCST Failure to Maintain Set 21.52 18.80 162.0 .489 .013 22.24 24.38 254.9 .563 .006 18.11 15.67 115.0 .486 .016 Explanations : CPT Commissions, t-scores; Tower, Tower Total Achievement Score. Abbreviations : Mr = Mean Rank *Means that represent a statistical significant difference with p < .05. Group differences pre-treatment EF There were significant differences between the groups in performance on tests CWIT-3 (See Table 2 ), TMT-4, Category Fluency, Tower, with medium to large effect sizes, and differences remained significant when controlling for processing speed (EF contrast scores). Differences on CWIT-4, letter fluency and WCST perseverative errors approached significance with medium effect sizes. In sum, patients performed worse than controls on all measures of EF pre-ECT, and the differences were significant on all variables except for the CWIT-4 contrast score, category switching, CPT commissions and WCST categories completed. Attention There were significant differences between groups on DST, DSST and CPT omissions at T1. Effect sizes on all tests showed medium to large effects. Pre-ECT, patients performed worse than controls on all tests of attention, except the WCST failure to maintain set. Difference in cognitive performance between groups at short-term and long-term follow ups (T2 and T3) EF : At T2, there were statistically significant differences between groups on the following measures: CWIT-3, CWIT-4, Letter Fluency, Category Fluency, Category Switching, TMT-4, Tower and WCST preservative errors. The effect sizes were medium to large. At T3 differences were still statistically significant between groups on these tests, in addition to CPT Commissions, with tests showing medium to large effect sizes. In sum, there were both significant short-and long-term differences between groups in all EF measures except WCST categories completed. Attention At T2 groups were statistically significantly different on DSST with large effect sizes. At T3 this difference remained. In addition, a significant difference between groups in performance on CPT omissions manifested, with medium effect size. In sum, there were both short-term and long-term significant differences between groups in processing speed, and long-term differences between groups in inattention scores. Short-term change in cognitive functions post-treatment (T1-T2) EF Patients demonstrated a statistically significant improvement in performance on CWIT-3 from T1 to T2 with a medium to large effect (See Table 3 ). Controls also showed significant improvement in CWIT-3 from T1 to T2 with a medium to large effect. Also, contrast scores for CWIT-3 showed significant improvement for the patient group with a medium to large effect size. The control group approached significant improvement with a medium effect. Patients demonstrated a medium improvement on the Tower test and a possible decline in verbal fluency switching, that approached significance, which was not evident in controls. The control group showed significant improvement on CPT Commissions from T1 to T2. Patients also showed an improvement on CPT Commissions that approached significance. Finally, controls showed a significant medium sized improvement in Letter Fluency from T1 to T2. In sum, the patient group and the control group showed significant short-term improvement in Inhibition indicating practice effects in both groups. Only the control group showed significant short-term improvement in Verbal Fluency. Attention There were no significant changes for attentional performance in the patient group from T1 to T2. The control group showed a statistically significant increase in performance on DSST from T1 to T2 with a large effect size. In sum, the control group showed short-term practice effect improvements in visual attention and processing speed, while patients showed no short-term improvement. Changes in cognitive functions from short-term to long-term follow-up (T2-T3) EF Patients demonstrated a statistically significant improvement in performance on CWIT-4 from T2 to T3 with a medium to large effect size. Controls also demonstrated a statistically significant improvement in performance on CWIT-4 from T2 to T3 with a large effect size. There was also a significant change in CWIT-4 contrast scores for both groups. In sum, both groups showed long-term improvement in Switching, indicating practice effects. Attention Patients showed a statistically significant increase in performance on DST from T2 to T3 with a medium to large effect size. On DSST patients also showed a statistically significant increase from T2 to T3 with a medium to large effect size. Controls showed a statistically significant improvement in CPT omissions with a moderate effect size. In sum, the patient group showed a significant long-term improvement in auditory attention, working memory, visual attention and processing speed, while controls did not demonstrate such improvement. The control group showed significantly less long-term inattention, indicating a practice effect. Changes from baseline to long-term follow-up (T1-T3) EF : Patients showed a statistically significant improvement in CWIT-3 and CWIT-3 contrast scores from T1 to T3 with large effect sizes. Patients also approached significant change in CWIT-4 with a large to medium effect size. Controls demonstrated significant improvement from T1 to T3 on the following tests: CWIT-4, Letter Fluency, Tower and CPT Commissions. In sum, the patient group showed long-term improvement in inhibition as the healthy controls showed long-term practice effects on several EF measures except in inhibition measured by CWIT-3. Attention From T1 to T3 patients showed a statistically significant increase in DSST from T1 to T3 with a large effect size. The patient group showed a significant increase in WCST failure to maintain set from T1 to T3 indicating a large effect size. Healthy controls showed a statistically significant improvement on DSST from T1 to T3 with a large effect size. In sum, both groups showed significant long-term improvement in visual attention, while only the patient group showed significantly more long-term inattention (See Table 4 for a summary of results). Table 4 Summary of findings: Differences in Executive- and Attentional functioning and changes in patients’ cognitive performance Pre ECT (T1) Post ECT (T2) 6 months following ECT (T3) Group differences (p < .05) Group differences (p < .05) Change in patient group from T1 (p < .05) Group differences (p < .05) Change in patient group from T1 (p < .05) Executive functions N Tests = 6/13 N Tests = 10/13 N Tests = 2/13 N Tests = 11/13 N Tests = 2/13 Inhibition CWIT-3 Inhibition ≠ ≠ ▲ ≠ ▲ CPT Commissions ≈ ≈ ≈ ≠ ≈ CWIT-3 Contrast ≠ ≠ ▲ .068 ▲ Flexibility/ Shifting CWIT-4 Inh/switch .069 ≠ ≈ ≠ .055 CWIT4 Contrast ≈ ≠ ≈ .081 ≈ Category Switching ≈ ≠ .055 ≠ ≈ TMT-4 (TMT-B) ≠ ≠ ≈ ≠ ≈ TMT-4 Contrast ≠ ≠ ≈ ≠ ≈ WCST CC ≈ ≈ ≈ ≈ ≈ WCST PE ≈ ≈ ≈ ≈ ≈ Verbal Fluency Letter Fluency .090 ≠ ≈ ≠ ≈ Category Fluency ≠ ≠ ≈ ≠ ≈ Planning ability Tower Achievement ≠ ≠ ≈ ≠ ≈ Attentional functioning N Tests = 3/4 N Tests = 2/4 N Tests = 2/4 N Tests = 2/4 N Tests = 2/4 Auditory Attention Working Memory Digit Span Test ≠ ≈ ▲ ≈ ≈ Visual attention Processing speed DSST ≠ ≠ ▲ ≠ ▲ Inattention CPT Omission ≠ .059 .066 ≠ ≈ WCST FMS ≈ ≈ ≈ ≈ ▲ CC = Categories Completed, CPT = Continuous Performance Test-II, CWIT = Color-Word Interference Test, DSST = Digit Symbol Substitution Test, ECT = Electroconvulsive therapy, FMS = Failure to Maintain Set, PE = Perseverative Errors, WCST = Wisconsin Card Sorting Test, N Tests = number of tests in each domain significantly different between groups or improved /total number of tests, ≠ significant difference between groups, ▲ significant improvement, ≈ no significant difference between groups ≈ no significant change in test score The relation between symptoms and cognitive function The bivariate correlation coefficients calculated for change scores in neuropsychological tests and change depressive symptoms did not reveal any significant results, except for inhibition measured by CWIT3 ρ ( 9 ) = .609, p = .047. Discussion The present study aimed to investigate short- and long-term effects of ECT on EF and attention. By exploiting the rapid antidepressant effect of ECT, changes in attentional and executive function in relation to trait/scar and state effects of depression were examined. The study found no indications of worsening general executive and attentional functions following ECT, as deficits apparent pre-treatment either persisted or improved following ECT. An improvement in specific aspects of EF and attention was evident in inhibition, visual attention, processing speed, auditory attention and working memory. However, results varied between tests within aspects for several of the executive functions and in certain aspects of attention. While patients six months after ECT reached a level of functioning comparable to healthy controls in auditory attention and working memory, impairments were still evident in visual attention, processing speed, inattention, and executive functions. Thus, findings in the present study provide support for both perspectives, with a state-related cognitive functional improvement following a significant antidepressant effect of ECT, in addition to persistent cognitive impairments that can be attributed to trait- or scar-related effects of depression. Do patients suffering from depression have reduced executive functions and attentional capacity when compared to healthy controls pre ECT? Regarding EF, the hypothesis with expected significant differences between groups at baseline was confirmed for most but not all measures. This is in line with meta studies of EF in MDD( 20 , 21 ). Patients demonstrated a significantly poorer ability to plan, as measured by the Tower Test. Patients showed deficits in one of the measures of inhibition (CWIT-3), while inhibition as measured by CPT commissions was not significantly poorer compared to controls, although with poorer performance showing small to medium effect size. Also, for verbal fluency, patients performed significantly worse in the category fluency condition. Patients did perform poorer than controls on letter fluency with a medium effect size, although group differences did not reach significance. Lastly, there were impairments in one measure of the aspect switching or mental flexibility (TMT-4). Differences were not significant when switching were measured with CWIT-4, although differences approached significance and showed medium effect size with patients performing worse than controls. As expected, patients showed reduced capacity in all aspects of attention when compared to healthy controls pre-ECT except in WCST failure to maintain set. This coincides with previous research pointing to impairments in various aspects of attention due to depression( 30 – 32 ). However, results differed between tests for the aspect of inattention, where patients performed significantly poorer on CPT omissions compared to controls, while performance did not differ significantly on WCST failure to maintain set. One possible explanation for the differing results could be that while CPT omissions will be affected by reaction time, WCST is not and, therefore might be less affected by the reduced processing speed in patients with depression. However, Stordal et al. ( 54 ) did find impairments in the WCST condition failure to maintain set also when adjusted for psychomotor speed. Impairments, defined as significant group differences, were identified for all measured aspects of attention and EF. Finding impaired attentional and executive functioning in patients aligns with previous studies on the neurocognitive profile in patients with MDD( 16 , 19 – 21 ). However, finding that patients performed worse overall, but not significantly different from controls on four measures of EF, could also be explained by a small sample size and insufficient power to detect medium sized effects consistently. Also, some tests of EF are likely less sensitive to the cognitive deficits experienced in MDD( 23 ). Do patients´ executive and attentional functions improve shortly and longtermly (6 months) post ECT? As hypothesized, EF and attentional capacity either improved or remained stable post-ECT. Results can be interpreted as supporting earlier findings, indicating that the domains of EF and attention are unharmed by ECT( 7 , 37 , 42 ). Separating the domains of EF and attention, in addition to discerning the respective aspects of these domains, we were able to identify some nuances adding to previous results, suggesting that some aspects of these functions improve. This was also possible due to the comparison of potential practice effects in the patient and control group. Patients did demonstrate an improvement in inhibition measured by CWIT3 from T1 to T3 that was not detected in controls. However, practice effects in inhibition were evident in the control group at the short-term follow-up and this might indicate that the control group had received a ceiling effect at the long-term follow-up or could be explained by lower statistical power due to smaller sample and drop out. Moreover, the patients still underperformed at the inhibition task after six months compared to the control group. Besides inhibition, there was not found any statistically significant change in any of the other measures of EF, which is in line with predictions of the trait- and scar-hypothesis. Contrary to a recent meta-analysis, the present study did not find short-term decline in letter fluency( 13 ). This could be explained by the low statistical power of the present study, but also the heterogeneity in time intervals for short term measures and patient groups included in the meta-analysis( 13 ). However, our study found a possible a short-term decline in category switching, however this finding approaching statistical significance should be further investigated in larger studies with more statistical power. The control group demonstrated statistically significant improvements on several measures that were not found in patients. Short-term changes included significant improvement in inhibition and verbal fluency. The control group showed a significant long-term improvement in inhibition, switching, verbal fluency and planning. As the control group showed a large improvement in verbal fluency which were not present in the patient group, the results could indicate that patients have lost practice effects, which could be either due to the depressive state or the ECT. In sum, there was no decline in patients' performance on executive measurements, in addition to significant long-term improvement or practice effects in patients´ ability to inhibit. Compared to patients, the control participants did demonstrate a greater improvement in verbal fluency, inhibition, switching and planning. This could indicate a missed practice effect for patients in measures of EF, or it could indicate a negative effect of treatment on performance. In this regard, the results do not rule out the possibility of iatrogenic effects of ECT on EF. However, the preexisting differences in most cognitive tests, in addition to the known effects of depression on neuroplasticity( 55 ), suggest that depression history, at least partly, could explain the relatively poor practice effects in the depression group( 16 ). This could be especially true for the current patient group undergoing ECT considering this treatment often is administered for particularly complex and severe cases of MDD. Regarding visual attention and processing speed, the patient group showed no short-term improvements, but had a statistically significant long-term improvement. Results thus indicate a positive effect of the symptom recovery following ECT on these aspects of attentional functioning. However, the control group also showed a long-term significant improvement on visual attention and processing speed, which may indicate that patients' improvements can be the result of a practice effect on longitudinal measurements. Results regarding processing speed support previous findings on how this aspect of attention is affected by the presence of depressive symptoms( 26 ), and results could therefore support the state-hypothesis. Also, a recent meta-analysis found processing speed improved following remission which also support this perspective ( 15 ). Still, group differences were present at all time points also indicating a trait or scar perspective on attention. Patients demonstrated a long-term improvement in auditory attention and working memory, where the latter is in line with previous findings ( 7 , 39 , 40 , 42 ). Both the groups showed significantly less long-term inattention, indicating practice effects. Are patients' executive and attentional abilities comparable to healthy controls shortly post ECT and at 6 month follow up? Compared to healthy controls, patients were expected to demonstrate residual impairment in both domains six months post ECT( 16 , 24 – 26 , 56 ). Comparing short- and long-term measures of EF in the two groups, control participants achieved significantly higher scores in all measured aspects of EF post-treatment. Patients performed significantly poorer compared to the control group on most EF variables at both the short- and long-term follow-up (T2 and T3). The results for attentional assessments were slightly more diverse. At the short-term follow-up (T2), results indicated comparable results for auditory attention, working memory and inattention, but not for processing speed and visual attention. Results also indicated comparable abilities for auditory attention and working memory at the long-term follow-up (T3). Significant differences were found in visual attention, processing speed and inattention at the six-month follow-up, where the patient group performed poorer than healthy controls. With some exceptions, results indicate stable differences in performance for EF, inattention, visual attention and processing speed from pre- to post-treatment. Patients have a stable tendency to score lower in these aspects when performance is compared to the performance of controls. These findings harmonize with previous research indicating that impairment seems to last beyond the depressed episode ( 15 , 16 , 25 , 26 ). Such findings align with the trait- and scar hypothesis for depression. However, indications for a state-effect were also identified through findings showing that patients reached a level of functioning comparable to healthy controls on post-treatment measures in certain aspects. Results could also be influenced by MADRS scores indicating considerable residual symptoms in the patient group at follow up. Finally, since there were no tests of the cognitive functioning of the patients before their illness, the trait perspective can only be inferred, not confirmed by the current study design. Will the cognitive profile following ECT show improvement in EF and attention related to mood symptoms (state) or show pre-post persistent impairments (trait or scar)? We did expect to find a relation between improvement in mood symptoms and cognitive functions for both EF and attention, but the present study only suggested such relation for the EF aspect of inhibition. Finding that change in inhibition score was related to change in depressive symptoms adds to previous findings that indicate a pattern of trait-related effects of depression on inhibition ( 18 ) showing significant differences in inhibition between groups despite mood symptom load. Still, the correlation between improvement in inhibition and improvement in mood identified in the present study aligns with the state-hypothesis, predicting that inhibition improves as the depressive symptoms decrease. Alternatively, or in addition, improvements in inhibition could be related to the antidepressant effects of ECT. However, the limited statistical power of this study and the small sample showing these effects warrants careful interpretations, and there is a need to test this relation with a larger sample size. Also, the low variance in depressive scores might have an impact on the present findings as well as the potential practice effects related to findings of improvement in the healthy control group as well. Still, by inspecting the long-term improvements in attention and psychomotor speed measures along with significant symptom improvement, this might strengthen a state perspective for these functions. Strengths, limitations and further directions The present study has several strengths and limitations that are recommended to be considered in future research. The longitudinal design enabled monitoring of changes over time and exploring the cognitive nature of depression as well as both immediate and long-term effects of ECT. However, future studies should also include longitudinal measurements beyond six months to further investigate long-term changes. Inclusion of a healthy control group has previously been a methodological shortcoming in ECT research( 13 ), and is included in the present study to identify deficits present pre-treatment. By including a healthy control group, we also controlled for potential practice effects and were able to differentiate between impairments attributable to treatment from impairments related to the depression per se. Heterogeneity in the use of ECT in research challenges the ability to compare results and may have contributed to inconclusive or mixed findings regarding cognitive side-effects of treatment. It is not uncommon that studies and meta-analysis lack a differentiation between different ECT procedures( 37 , 42 ). This represents a challenge when modern and older ECT practices are associated with different outcomes in cognitive function ( 13 ). Consequently, standardization of ECT-procedures should be pursued. Further, there is a need for standardizing test batteries used in ECT studies, as there is great variation in the application of neurocognitive tests. To account for this, a variety of established neuropsychological tests were administered in the present study, and such cognitive tests are strongly recommended to include in routine ECT follow-up ( 13 ). Also, our study indicates that some aspects of WCST are not sensitive to cognitive deficits in MDD. A limitation of the present study is that it did not include any self-report measures, which may lead to an incomplete understanding of the extent of persistent or improved cognitive difficulties. Autobiographical memory loss is often of concern following ECT ( 14 ). The discrepancy between subjective and objective outcomes after ECT ( 41 ) should be explored further and subjective measures included to provide a more comprehensive understanding of cognitive change. Matching for demographic variables could be important in research on MDD ( 12 , 57 ). In the present study, both patients and healthy controls were comprehensively examined in terms of demographic parameters. Correspondingly, the control group had statistically significant higher education and IQ, which can have influenced cognition and thus the validity of the present results. In future research, we suggest efforts are made to match demographic variables between patients and healthy controls, however this is not always indicated, e.g. when the condition being are studied influences these aspects( 58 ). The inclusion of patients with both bipolar and unipolar depressive disorder gives the study a broad ecological valid, and representative, sample. However, both groups consist of small samples, making subgroup comparisons difficult. In addition, the current study has a substantial amount of missing data. Late inclusion of patients and a high drop-out rate is the reason for this. As a consequence of missing data and sample size, it is possible that some group differences or changes in attentional and EF were undetected and that findings were influenced by attrition effects. Results should be interpreted accordingly. Further examination is needed to clarify how ECT and depression affect cognitive functions in patients with severe and treatment-resistant depression, in large, matched samples, with long follow-up time and tests assessing several domains of cognition. To best address potential iatrogenic effects of ECT, patients with depression matched on clinical and demographic variables could be compared on ECT if one group underwent ECT, and one did not. Clinical implications Results from this study are useful for both practitioners and patients. Findings can contribute to providing patients with more nuanced information regarding potential side effects of ECT treatment, in addition to awareness about impairments that can be attributed to the depression itself, and that the deficits reported by patients can be influenced secondary to reduced EF and attention caused by ECT. Even after treatment, our results show lasting cognitive difficulties when compared to a healthy group. Such knowledge can be used to normalize patients' experience of cognitive impairments. Also, findings suggest that cognitive remediation interventions could be useful in this group( 59 ). It is important to acknowledge that our results are based on group-level analyses and hence cannot be used to refute the fact that a few patients may experience adverse effects following ECT( 60 ). Also, it is known that autobiographical memory consistency is reduced following ECT( 61 ), but this was not investigated in the present study. More detailed knowledge about side-effects of ECT as provided in this study can strengthen clinicians and patients´ ability to make informed decisions about ECT treatment and predict risk and benefits associated with treatment. Importantly, by finding mostly positive and neutral effects of ECT on tests of EF and attention, this study may contribute to reducing the stigma associated with the treatment. Reducing stigma and clarifying side-effects could be a key factor to minimize underutilization of a treatment option that besides being lifesaving has the potential to improve patients functioning and quality of life. Conclusions Overall, this study did not find indications of worsening of performance after ECT on either aspects of attention or executive functions in patients with depression. However, the control group showed improved performance in some aspects and this might indicate lost practice effects for the patient group. Patients demonstrated both short- and long-term improvement in several aspects of cognitive function, alluding to a possible state-related improvement following symptom relief, still with significant difference in performance compared to the control group. More specifically, patients showed significant improvement in auditory attention, working memory, visual attention, processing speed and inhibition from pre- to post measures. However, group differences identified both pre- and post ECT indicated persistent impairments in EF and some aspects of attention (visual attention, processing speed and inattention) that are interpreted as supporting a trait- or scar effect of depression on cognitive function. In conclusion, it can be inferred that the cognitive profile following ECT is differential, with some aspects of cognitive functions improving along symptom reduction, while others remain impaired related to the enduring effects of depression or inherent vulnerability traits. Abbreviations ECT Electroconvulsive treatment MDD major depressive disorder MADRS Montgomery Aasberg Depression Rating Scale IQ intelligence quotient D-KEFS Delis-Kaplan Executive Function System Wisconsin Card Sorting Test WCST Continuous Performance Test CPT Color-Word Interference Test CWIT Trail Making Test TMT Digit Symbol Substitution Test DSST Digit Span Test DST Declarations Ethics approval and consent to participate: Written and informed consent from participants was collected in advance of participation. All participants consented to participation in the study. The study was approved by the Regional Committee for Medical and Health Research Ethics, South East, ID: 2013/1032 ECT and neurology. Consent for publication: Not applicable. Competing interests: None of the authors have any competing interests to declare. Funding: Helse Vest (Western Norway Regional Health Authority) − 911986 [Oedegaard], Helse Vest (Western Norway Regional Health Authority) − 912238 [Oltedal] Author Contribution EHR and ÅH share first authorship and supervised the writing of the first draft, designed the research questions and wrote final draft of in the current paper. EHR performed and supervised analysis and creating of tables. RU and MAS wrote the first draft of the paper. performed analysis and created tables. UK, KJØ and LO helped perform the study commented and edited the manuscript. All authors approved the final paper for submission. Acknowledgement We would like to acknowledge the funders, and the patients, as well as collaborating health care institutions. Finally, Leila Frid is acknowledged for her part in running the study and assessing participants. Your efforts are greatly appreciated. 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J Nerv Mental Disease september. 2012;200(9):773–6. Frid LM, Kessler U, Ousdal OT, Hammar Å, Haavik J, Riemer F. mfl. Neurobiological mechanisms of ECT and TMS treatment in depression: study protocol of a multimodal magnetic resonance investigation. BMC Psychiatry 30 oktober. 2023;23(1):791. Dennis M, Francis DJ, Cirino PT, Schachar R, Barnes MA, Fletcher JM. Why IQ is not a covariate in cognitive studies of neurodevelopmental disorders. J Int Neuropsychol Soc mai. 2009;15(3):331–43. Van De Velde N, Kappen M, Koster EHW, Hoorelbeke K, Tandt H, Verslype P. mfl. Cognitive remediation following electroconvulsive therapy in patients with treatment resistant depression: randomized controlled trial of an intervention for relapse prevention – study protocol. BMC Psychiatry desember. 2020;20(1):453. Sellevåg K, Bartz-Johannessen CA, Oedegaard KJ, Nordenskjöld A, Mohn C. Bjørke JS, mfl. Unmasking Patient Diversity: Exploring Cognitive and Antidepressive Effects of Electroconvulsive Therapy. Eur Psychiatr 12 januar 2024;1–34. Semkovska M, Knittle H, Leahy J, Rasmussen JR. Subjective cognitive complaints and subjective cognition following electroconvulsive therapy for depression: A systematic review and meta-analysis. Aust N Z J Psychiatry januar. 2023;57(1):21–33. Table 3 Table 3 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table3.docx Cite Share Download PDF Status: Published Journal Publication published 20 Nov, 2024 Read the published version in BMC Psychiatry → Version 1 posted Editorial decision: Revision requested 26 Sep, 2024 Reviews received at journal 25 Sep, 2024 Reviews received at journal 19 Sep, 2024 Reviewers agreed at journal 16 Sep, 2024 Reviewers agreed at journal 14 Sep, 2024 Reviewers invited by journal 14 Sep, 2024 Editor invited by journal 13 Sep, 2024 Editor assigned by journal 13 Sep, 2024 Submission checks completed at journal 12 Sep, 2024 First submitted to journal 02 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Oedegaard","email":"","orcid":"","institution":"Haukeland University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Ketil","middleName":"J.","lastName":"Oedegaard","suffix":""},{"id":359175566,"identity":"ecde5225-edde-4afe-b4f6-b87acee8c3b0","order_by":6,"name":"Leif Oltedal","email":"","orcid":"","institution":"University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Leif","middleName":"","lastName":"Oltedal","suffix":""}],"badges":[],"createdAt":"2024-09-02 15:40:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5019584/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5019584/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12888-024-06270-5","type":"published","date":"2024-11-20T15:57:20+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69835166,"identity":"a917d913-c9b5-443a-8dde-dbd75a20b3db","added_by":"auto","created_at":"2024-11-25 16:12:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1577123,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5019584/v1/a3e4fc26-4cc2-434b-9755-248456fb750e.pdf"},{"id":68531842,"identity":"9ae5f3f5-913b-4ce6-9c32-950c24f3fa56","added_by":"auto","created_at":"2024-11-08 09:19:12","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24209,"visible":true,"origin":"","legend":"","description":"","filename":"Table3.docx","url":"https://assets-eu.researchsquare.com/files/rs-5019584/v1/6d4f31bfd11da51669331a75.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Improvement of persistent impairments in Executive Functions and Attention following Electroconvulsive therapy in a case control longitudinal follow up study","fulltext":[{"header":"Background","content":"\u003cp\u003eDepression is one of the leading causes of disability worldwide and largely contributes to the global burden of disease(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), through substantial functional impairment(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Although there are effective treatments targeting depression, over one third of patients do not respond to first line interventions and could be considered treatment-resistant(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Electroconvulsive therapy (ECT) represents one of the most effective treatments of severe and depression(\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), with high remission rates even in cases of treatment-resistant depression(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). However, ECT is often used as a treatment of last resort(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e), possibly due to stigma(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and concerns about adverse side effects(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Despite accumulating evidence of its safety and effectiveness, it is still unclear to what degree ECT can cause persistent neurocognitive deficits in some patients treated for depression(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Enhanced knowledge about possible short- and long-term side-effects of ECT is considered crucial for improving clinicians and patients\u0026rsquo; ability to make informed decisions about treatment. Major Depressive Disorder (MDD) is associated with cognitive impairments(\u003cspan additionalcitationids=\"CR16 CR17\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), in remission and worsening with the duration of depressive episodes(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Different perspectives exist regarding the etiological nature of neurocognitive impairment in MDD. These vary regarding the view on impairments could be either a pre-existing vulnerability (trait) or related to the depressive symptom load (state), or a consequence of progressive scarring due to neurotoxic effects of depression (scar)(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). There is some support in the literature for all three perspectives(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), and examining changes in different domains of cognition following the rapid ECT-treatment effect of depression could inform on these perspectives.\u003c/p\u003e \u003cp\u003eExecutive functions (EF) and attention are two of the neurocognitive domains significantly affected in patients suffering from depression(\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e), with impairments still evident in remission(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). EF are needed to manage most of our daily activities and underlie our ability to organize thinking(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), self-regulate, plan, inhibit and make decisions(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). When EF is measured objectively with standardized neuropsychological tests, people with MDD tend to perform significantly worse compared to healthy controls on tasks measuring aspects of EF such as shifting, inhibition and verbal fluency in the acute state of depression(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e), persisting beyond the depressive episode(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). These findings indicate a possible trait- or scarring effect of depression on EF, however the research is inconclusive regarding which aspects of EF are affected by scarring(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), or by ECT(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Measuring different aspects of EF pre- post ECT could inform on this.\u003c/p\u003e \u003cp\u003eSimilar to EF, attention is an associated multidimensional construct and a selection mechanism(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e), that allows control of limited cognitive resources in a flexible manner(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), and is closely related to processing speed(\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). There is support in the literature for attentional deficits during the acute state of depression, although findings are inconsistent regarding which aspects of the attentional domain that are affected(\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In addition, there are findings indicating that the severity of depressive symptoms could influence the extent of impairment(\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Although attentional deficits are shown to persist in remission(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e), they are smaller compared to the acute state(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In line with this, recent studies suggest that attentional functioning improves following treatment(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e), indicating a possible state-effect of depressive symptoms on attention. However, various aspects of attention could be influenced differently, and patient group characteristics, such as severity of depression and duration is related to both improvement and impairment(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Investigating aspects of attention pre- post ECT could provide insight on the relationship between attention and depressive symptoms and severity, as well as the impact of ECT.\u003c/p\u003e \u003cp\u003eResearch on depressed patients treated with ECT indicate no lasting treatment induced deficits in objective measures of EF and attention(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR38 CR39 CR40\" citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e). However, an acute decline in attention and the executive aspect of inhibition was observed at the initiation of ECT-treatment but normalized after completion of treatment sessions(\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Small decreases have been reported in verbal fluency shortly after ECT in heterogeneous patient samples(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Small to medium improvements have been reported for shifting, inhibition and planning, and recovery of baseline levels for verbal fluency in long-term measures post ECT(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Attentional functioning is shown to improve both short- and long-term post ECT-treatment(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), particularly in the aspects of processing speed and working memory(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). However, executive and attentional functioning in patients is still not comparable to healthy controls post ECT(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), making it difficult to draw conclusions regarding the effects of ECT versus the effects of depression in relation to the state, trait and scar hypotheses.\u003c/p\u003e \u003cp\u003eImportantly, there are several methodological shortcomings concerning previous research examining the effects of ECT on cognition that constrains the state of knowledge(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Firstly, there are few studies investigating longitudinal effects of ECT on cognition (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Previous studies also lack inclusion of a healthy control group, which challenge controlling for practice effects due to repeated testing(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Studies also vary regarding how ECT as an intervention is applied, the timing of measurements and neuropsychological assessments(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In addition, both EF and attention could influence other cognitive functions like memory(\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), and thus the development of these functions following treatment is important for separating the cognitive residual symptoms related to depression history from side effects reported following ECT. Lastly, results from the same neuropsychological tests are being reported and interpreted differently, partly due to assumptions that the same tests are tapping multiple cognitive processes(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). In the present study, these issues are reduced by including several outcome measures from both the executive and attentional domain.\u003c/p\u003e \u003cp\u003ePrior research has faced challenges in effectively differentiating the effects of depression and ECT on cognitive functioning. This is rectified in the present study by including baseline measures and a healthy control group, to examine whether side-effects identified post ECT are treatment-induced, or if findings coincide with research demonstrating long-term cognitive impairment following severe depression(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). In addition, by utilizing the rapid antidepressant effect of ECT(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), our design allows for innovative exploration of the scar, trait and state perspectives in relation to the domains of executive and attentional functioning. While the state perspective would predict recovery of cognitive functions following ECT-treatment and symptom relief, the trait and scar perspectives would predict preexisting, lasting neurocognitive deficits, and even exacerbation of cognitive functions. Including a variety of measures and separating the domains of EF and attention enables identifying potential domain and aspect specific profiles.\u003c/p\u003e"},{"header":"Objectives and Main Aim","content":"\u003cp\u003eThe main aim of this study is to investigate short- and long-term effects of ECT on objective and standardized tests of both executive and attentional functioning in patients with major depression. By using a healthy control group for comparison, the study estimates both changes within groups but also compares whether the patient group reaches a level of cognitive functioning that corresponds to healthy controls and differs in change compared to controls. Lastly, we aim to investigate the cognitive profile following ECT related to the state-, scar and trait-perspectives, and if these profiles are domain- or aspect-specific. Since the design will not allow a differentiation of whether persistent deficits are related to trait vulnerability or scarring, these two perspectives will be compared to the state perspective. The following research questions were formulated:\u003c/p\u003e \u003cp\u003e \u003cb\u003eResearch questions\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDo patients suffering from depression have reduced executive functions and attentional capacity when compared to healthy controls pre ECT?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDo patients\u0026acute; executive and attentional functions improve shortly and long-termly (6 months) post ECT?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAre patients' executive and attentional abilities comparable to healthy controls shortly post ECT and at 6 month follow up?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWill the cognitive profile following ECT show improvement in EF and attention related to mood symptoms (state) or show pre-post persistent impairments (trait or scar)?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eHypotheses\u003c/h2\u003e \u003cp\u003eBased on the previous literature regarding cognitive impairments in depression, we expect patients with MDD to have significantly poorer performance on all tests measuring attention and EF at baseline compared to healthy controls. Compared to baseline, patients' performances are expected to either improve or remain stable shortly post-treatment. As some findings indicate short-term declines in verbal fluency, while others show normalization to baseline levels, it remains unclear whether to expect a transient decline or baseline levels for verbal fluency shortly post-treatment. At six-month follow-up, we expect patients\u0026rsquo; performance on all tests to either improve or return to baseline level. Specifically, we expect long-term improvement in the aspects of processing speed and working memory. However, we still expect patients to perform significantly worse compared to healthy controls. It is therefore expected that we will find both state-related function improvement, but also lasting impairment that is in line with trait- or scar-related effects of depression. Finally, we expect a significant improvement in depressive symptom load following ECT.\u003c/p\u003e \u003c/div\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eA pre-post intervention longitudinal follow up study was conducted (Oltedal et al., 2015), and data were collected at baseline prior to receiving ECT (T1), approximately 2 weeks post-treatment (T2) and 6 months post-treatment (T3). Patients were compared to a healthy control group that underwent repeated neuropsychological testing at the same time points as the patients. Clinical trial number: not applicable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eThe original patient group consisted of forty (n\u0026thinsp;=\u0026thinsp;40) participants who were referred to Haukeland University Hospital, Bergen, Norway, for ECT. Eligibility criteria included patients over the age of 18, with no upper age limit for participation, referred to ECT due to a moderate or severe depressive episode according to guidelines from Norwegian Health Department (2017). This usually entails lack of effect from conventional treatments and/or life-threatening depression. All patients fulfilled the criteria for one of the following ICD-10 diagnoses: F31.3 (10,3%) and F31.4 (7,69%); F32.1 (2,56%) and F32.3 (5,13%); F33.1 (12,32%) and F33.2 (56,41%) and F33.3 (5,13%). To be included, patients had to score 25 or higher on Montgomery Aasberg Depression Rating Scale (MADRS). Patients with both bipolar and unipolar depression were included. Exclusion criteria were pregnancy, an intelligence quotient (IQ) of \u0026le;\u0026thinsp;70 and a history of receiving ECT within the last 12 months. One patient was excluded due to an IQ score under 70. Twenty-six (n\u0026thinsp;=\u0026thinsp;26) patients underwent neuropsychological testing at T1. Twenty (n\u0026thinsp;=\u0026thinsp;20) patients returned for testing at short-term follow up (T2), with a late inclusion of ten (n\u0026thinsp;=\u0026thinsp;10) patients, resulting in a total of thirty patients measured at T2 (n\u0026thinsp;=\u0026thinsp;30). A total of nineteen (n\u0026thinsp;=\u0026thinsp;19) patients returned for 6-month follow up (T3).\u003c/p\u003e \u003cp\u003eThe control group consisted of sixteen (n\u0026thinsp;=\u0026thinsp;16) healthy controls of equivalent mean age and sex distribution as patients. Fifteen (n\u0026thinsp;=\u0026thinsp;15) participants from the control group were assessed with the neuropsychological testing at T1, sixteen (n\u0026thinsp;=\u0026thinsp;16) were assessed at T2, and fifteen (n\u0026thinsp;=\u0026thinsp;15) participants returned for 6 months follow-up. Details on participant demographics are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics at Baseline for all Participants and Attrition Patients\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003ePatients (n\u0026thinsp;=\u0026thinsp;36)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eControls (n\u0026thinsp;=\u0026thinsp;16)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003eAttrition Patients\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eMean T2 (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eMean T3 (n\u0026thinsp;=\u0026thinsp;12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e42.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e42.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e40.42\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale/female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18/18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5/10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13.75*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e16.31*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e10.8**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e13.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal IQ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106.22*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e120*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e97.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMADRS T1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33.54*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.92*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e34.33\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMADRS T2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.08*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.08*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMADRS T3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14.5*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.77*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"9\" nameend=\"c9\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMADRS, Montgomery Aasberg Depression Rating Scale; NA, not applicable. *Means that are significantly different between groups with p\u0026thinsp;\u0026lt;\u0026thinsp;0.01.\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eAttrition: ** Means on variables where drop-out participants are significantly different (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eECT Treatment\u003c/h2\u003e \u003cdiv id=\"Sec8\" class=\"Section3\"\u003e \u003ch2\u003eStimulus and Electrode Placement\u003c/h2\u003e \u003cp\u003ePatients received three sessions with ECT per week until remission, or until the maximum of 18 sessions was reached. Patients underwent right unilateral electrode placements with a Thymatron System IV (Somatics LLC, Lake Bluff, Illinois) providing brief-pulse, square wave, constant current.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eStimulus\u003c/h2\u003e \u003cp\u003eThe initial stimulus energy was calculated based on gender and age, and the duration of the stimulus pulse was set to 0.5 ms.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eAnesthesia\u003c/h2\u003e \u003cp\u003eThiopental or Propofol was given as anesthesia. Patients were hyperoxygenated with oxygen-enriched air, minutes before and during anesthesia to optimize the induction of seizures.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSeizure Adequacy\u003c/h2\u003e \u003cp\u003eThe adequacy of each seizure was evaluated by an ECT-clinician based on duration, reorientation time, clinical effect, and d-waves. Seizures that were evaluated by the ECT-clinician as not effective led to restimulation in the same session, and/or adjustment of the stimulus parameter in the following session. For specific information about the ECT treatment, see(\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical Measures\u003c/h2\u003e \u003cp\u003eThe severity of the current depressive episode was verified and monitored by the MADRS scale(\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) at T1, T2 and T3.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNeurocognitive Assessment\u003c/h2\u003e \u003cp\u003eNeuropsychological tests were administered by a trained technician and consisted of standardized tests measuring attentional resources and executive functions. Wechsler Abbreviated Scales of Intelligence(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e) was administered as estimate of general abilities (IQ).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eExecutive Functioning\u003c/h2\u003e \u003cp\u003eFour tests from the Delis-Kaplan Executive Function System (D-KEFS(\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e)) were administered to measure aspects of executive functioning, with seven outcome variables included in analysis. In addition, the Wisconsin Card Sorting Test (WCST(\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e)) and the Continuous Performance Test-II (CPT(\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e)) were included.\u003c/p\u003e \u003cp\u003e\u003cb\u003eInhibition\u003c/b\u003e was measured using the Color-Word Interference Test (CWIT). In the third condition of CWIT, measuring inhibition, participants are expected to identify the color ink of the word and suppress the response to read the word. In addition to this, the number of commissions on CPT was used as an estimate of inhibition ability. The number of commission errors is the number of times participants incorrectly press the key when seeing \u0026ldquo;X\u0026rdquo;. High scores correspond to poor performance in the inhibition tasks.\u003c/p\u003e \u003cp\u003e\u003cb\u003eMental Flexibility or Shifting\u003c/b\u003e was measured using the fourth condition of CWIT, inhibition/switching, where participants are asked to switch from color naming of an incongruent word (CWIT 3) to reading (CWIT 2) when the word appears within a frame. In this task, high scores correspond to poor performance. In addition, the Category Switching condition of the Verbal Fluency test was included to measure flexibility and shifting. Category switching measures participants' ability to alternate between naming members of different categories, where higher scores equal better performance. Shifting was also measured using the number-letter switching condition of the D-KEFS Trail Making Test Part 4 (similar to TMT-B). In TMT- 4 participants have to shift between connecting letters and numbers, measured as time to complete the task. Therefore, higher scores correspond to poorer performance. In the WCST participants are asked to sort cards by different dimensions, such as color or shape, which demands maintaining or switching of rules in response to feedback. The number of successful switches between category sets and perseverative errors, which is applying an older previous rule for sorting, was used as an estimate for shifting ability. A high score on the WCST perseverative errors would indicate poor performance, while the contrary is true for WCST categories completed.\u003c/p\u003e \u003cp\u003e\u003cb\u003eVerbal Fluency\u003c/b\u003e was measured using D-KEFS Verbal Fluency Test consisting of the conditions: Letter Fluency and Category Fluency. Letter fluency is measured by asking patients to generate as many words as possible starting with a certain letter, while semantic verbal fluency is naming as many words as possible from a semantic category. In both measures of verbal fluency, higher scores equal good performance.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePlanning ability\u003c/b\u003e was measured using the Total Achievement Score of the Tower Test. Using as few moves as possible, the task of the D-KEFS Tower Test is to reproduce a pictured tower model, following a set of rules. For the Tower Test, higher scores indicate greater performance.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eAttentional functioning\u003c/h2\u003e \u003cp\u003eFour tests were administered to measure aspects of attentional resources; Digit Symbol Substitution Test (DSST(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)) Digit Span Test (DST(\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e)), omission errors in CPT and failure to maintain set in WCST.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAuditory Attention and Working Memory\u003c/b\u003e were measured with DST. A sequence of numbers is read aloud to participants, who are then asked to repeat the sequence in the same (attention) or backward (working memory) order as presented. The number sequences get progressively longer. Low scores on DST equals poor performance.\u003c/p\u003e \u003cp\u003e \u003cb\u003eVisual Attention and Processing Speed\u003c/b\u003e were measured with the DSST. Participants are asked to match symbols to numbers according to a template. Within a given time frame, participants copy the symbols into empty spaces below a row of numbers. The number of correct symbols within the time frame constitutes the score, where low scores equaled poor performance.\u003c/p\u003e \u003cp\u003e\u003cb\u003eInattention\u003c/b\u003e was measured with omission errors in CPT and failure to maintain set in WCST. In CPT participants are asked to press a key every time a letter appears on a computer screen, except for the letter \u0026ldquo;X\u0026rdquo;. Failure to press the key when a letter is displayed is an omission error and indicates inattentiveness or a lack of sustained attention. Failure to maintain set in the WCST is measured by the number of times a participant incorrectly changes their sorting strategy after the rule is known and before change is appropriate. High scores equal poor performance in both inattention tasks.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eEthics\u003c/h2\u003e \u003cp\u003e Written informed consent from participants was collected in advance of participation. The study was approved by the Regional Committee for Medical and Health Research Ethics South East, ID: 2013/1032 ECT and neurology.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eStatistics, Contrast- and Change Scores\u003c/h2\u003e \u003cp\u003eAll statistical analyses were performed in IBM SPSS Statistics version 28 (IBM Corp, Armonk, New York). One-way ANOVA tests were performed to assess differences between groups in demographic variables, symptomatology, results on neuropsychological tests at all time points, attrition effects from the patients that dropped out, and differences between change scores. A one-way between-group ANOVA was conducted to explore the impact of ECT on EF and attention in patients with MDD. Outcome measures were assessed for normality and Mann-Whitney U-tests were used as a nonparametric alternative to examine group differences in performance on three outcome variables of the WCST (preservative errors, failure to maintain set, categories completed) and on CPT omissions, and Lenhard et al. (\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e) was used to calculate eta squared for these tests. All variables consisted of raw scores, except for CPT where t-scores were used. Dependent samples t-test were done to assess changes in cognitive functioning. A paired-samples t-test was conducted to evaluate the impact of ECT on EF and attentional functioning in patients with major depression. Paired-samples t-tests were also conducted on means for the control group to detect retest/practice effects. Results are not corrected for multiple comparisons, as conducting a Bonferroni correction would result in low power to detect significant findings due to the small sample size and drop-out rates in the study. Contrast scores for investigating EF relatively independent from processing speed(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), were calculated by the following formulas: Inhibition contrast\u0026thinsp;=\u0026thinsp;CWIT 3 \u0026ndash; (CWIT 1\u0026thinsp;+\u0026thinsp;CWIT 2)/2, Mental/flexibility contrast\u0026thinsp;=\u0026thinsp;CWIT 4 \u0026ndash; (CWIT 1\u0026thinsp;+\u0026thinsp;CWIT 2\u0026thinsp;+\u0026thinsp;CWIT 3)/3, Shifting contrast\u0026thinsp;=\u0026thinsp;TMT 4 \u0026ndash; (TMT 1\u0026thinsp;+\u0026thinsp;TMT 2\u0026thinsp;+\u0026thinsp;TMT 3\u0026thinsp;+\u0026thinsp;TMT 5)/4. Change scores were calculated subtracting follow up test results and MADRS scores from baseline so that positive values indicated improvements(\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Bivariate correlation coefficients were calculated for change scores in neuropsychological tests and depressive symptoms. Significance level was set at \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.05. Effect sizes were described as small, medium and large according to Cohen (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n\u003ch2\u003eDemographic variables, clinical measures and attrition effects\u003c/h2\u003e\n\u003cp\u003eOne-way ANOVA revealed that the patient group had a significantly lower IQ and had fewer years of education in comparison with the control group (See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). Regarding attrition effects, patients lost to follow-up from T1 to T2 had significantly fewer years of education compared with participating patients. There were no significant differences in any of the other demographic variables for patients lost to follow-up.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab2\" style=\"width: 1003px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eDifferences between groups at T1, T2 and T3\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eTime\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 254px;\" colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003ePre-ECT (T1)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 256px;\" colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003ePost-ECT (T2)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 265.907px;\" colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003e6-month (T3)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eGroups n\u003c/p\u003e\n\u003cp\u003e(male/female)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003ePatients\u003c/p\u003e\n\u003cp\u003en = 26\u003c/p\u003e\n\u003cp\u003e(18/18)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\n\u003cp\u003e(5/10)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 124px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eStatistics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003ePatients\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;30\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;16\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 133px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eStatistics\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003ePatients\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;19\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003eControl\u003c/p\u003e\n\u003cp\u003en\u0026thinsp;=\u0026thinsp;15\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 132px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eStatistics\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eOutcome variable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003eM(SD)\u003c/p\u003e\n\u003cp\u003e/Mr\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003eM(SD)\u003c/p\u003e\n\u003cp\u003e/Mr\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003eF(df)\u003c/p\u003e\n\u003cp\u003e/U\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003eEta sq.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003eM(SD)\u003c/p\u003e\n\u003cp\u003e/Mr\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003eM(SD)\u003c/p\u003e\n\u003cp\u003e/Mr\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e(1)\u003c/p\u003e\n\u003cp\u003e/U\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003eEta sq.\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003eM(SD)\u003c/p\u003e\n\u003cp\u003e/Mr\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003eM(SD)\u003c/p\u003e\n\u003cp\u003e/Mr\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eF\u003c/em\u003e(1)\u003c/p\u003e\n\u003cp\u003e/U\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003eEta sq.\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eEF\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCWIT-3 Inhibition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e70* (28.4)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e49.8* (9.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e7.1 (1,38)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.011\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.157\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e67.8* (27.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e47.8* (9.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.289 (1, 44)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.006\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.159\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e66.3* (29.7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e49*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(9.7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e4.672 (1,32)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.038\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.127\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCWIT-3 Contrast scores\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e38.9* (23.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e23.4* (6.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e6.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.015\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.146\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e36.6* (22.7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e21.4* (6.2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e6.811\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.012\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.134\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e36.42 (25.81)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e23.27 (8.44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e3.572\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.068\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.100\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCWIT-4 Inhibition/switching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e73.2 (28.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e58.7(13.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e3.501\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.069\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e.084\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e78.8* (32)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e55.2* (11.7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.07\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.007\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.155\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e70.11* (30.75)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e51.93* (10.08)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e4.802\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.036\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.13\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCWIT4 Contrast scores\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e29.2 (17.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e24.4 (9.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e.947\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.337\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e.024\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e35.3* (22.9)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e22.1* (8)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e5.002\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.03\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.102\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e28.07 (20.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e18.44 (8.29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e2.817\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.103\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.081\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eLetter Fluency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e39.9 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e46.4 (12.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e3.026\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.090\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e.074\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e36.6* (12.3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e49.6* (13.3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10.764\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.002\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.2\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e33.9* (11.21)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e53.47* (13.47)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e21.391\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.401\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCategory Fluency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e41* (8.4)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e52.7* (10.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e15.663\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.292\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e40.2* (9.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e52.2* (9)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e17.020\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.284\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e38.11* (8.01)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e51.4* (9.16)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.353\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.389\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCategory Switching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e13.8 (2.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e14.7 (3.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e.784\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.382\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e.020\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e12.55* (2.76)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e14.4* (2.6)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e4.68\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.036\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.098\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e12.16* (2.36)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e15.53* (2.47)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e16.408\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.339\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eTMT-4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e100.3* (42.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e61.6* (19.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e10.978\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.002\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.229\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e100.8* (47)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e63.1* (27.4)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.606\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.005\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.167\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e100.22* (46.06)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e65.87* (26.04)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e6.57\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.015\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.175\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eTMT-4\u003c/p\u003e\n\u003cp\u003eContrast scores\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e76.7* (37.7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e44.3* (17.9)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e9.641\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.004\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.207\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e77.2* (40.2)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e45.9* (23.5)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.141\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.007\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.159\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e76.07* (38.19)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e49.11* (21.78)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e5.866\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.021\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.159\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eTower Total Achievement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e16.9* (3.3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.1* (3.7)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e8.226\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.007\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.178\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e17.6* (3.3)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.8* (3.1)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e9.482\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.004\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.184\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e17.78* (4.32)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e22.8* (4.16)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e11.434\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.002\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.269\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCPT Commissions (t-scores)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e55.9 (13.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e50.2 (10)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e1.981\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.167\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e.05\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e49.6 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e44.5 (7.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e2.744\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.105\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.06\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e51.48* (9.54)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e43.41* (6.21)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e7.801\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.009\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.206\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eWCST Categories Completed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e19.96\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e21.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e201\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.72\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e0.004\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e22.69\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e23.56\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e241\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.666\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e16.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e17.97\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e149.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.606\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e0.008\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eWCST Perseverative Errors\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e23\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e16.33\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e125\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.083\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e0.076\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e26.72\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e16.25\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e124\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.01\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.146\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e20.92\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e12.3\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e64.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.009\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e0.197\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAttention\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eDST\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e12.04*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2.14)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13.93*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(2.93)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e5.64\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.022\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.126\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e12.65\u003c/p\u003e\n\u003cp\u003e(2.56)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e13.37\u003c/p\u003e\n\u003cp\u003e(2.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e.78\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.380\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e12.84\u003c/p\u003e\n\u003cp\u003e(2.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e14.06\u003c/p\u003e\n\u003cp\u003e(3.86)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e1.19\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.282\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.036\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eDSST\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e43.31*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(14.38)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e59,93*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(11.68)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e14.47\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.271\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e44.58*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(17.68)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e63.62*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(14.64)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13.42\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.238\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e46.21*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(14.69)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e65.20*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e(12.20)\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e16.19\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lt;\u0026thinsp;.001\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.336\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eCPT omission\u003c/p\u003e\n\u003cp\u003e(t-scores)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e23.86\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e14.90\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e103.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.018\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.138\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e25.74\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e18.03\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e152.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.059\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.079\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e19.56\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e13.03\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e75.5\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.049\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003e.12\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 128px;\" align=\"left\"\u003e\n\u003cp\u003eWCST Failure to Maintain Set\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e21.52\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 66px;\" align=\"left\"\u003e\n\u003cp\u003e18.80\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 50px;\" align=\"left\"\u003e\n\u003cp\u003e162.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.489\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 35px;\" align=\"left\"\u003e\n\u003cp\u003e.013\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e22.24\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 59px;\" align=\"left\"\u003e\n\u003cp\u003e24.38\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 57px;\" align=\"left\"\u003e\n\u003cp\u003e254.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.563\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.006\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 69.9074px;\" align=\"left\"\u003e\n\u003cp\u003e18.11\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 64px;\" align=\"left\"\u003e\n\u003cp\u003e15.67\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 56px;\" align=\"left\"\u003e\n\u003cp\u003e115.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 39px;\" align=\"left\"\u003e\n\u003cp\u003e.486\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"width: 37px;\" align=\"left\"\u003e\n\u003cp\u003e.016\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd style=\"width: 907px;\" colspan=\"16\" align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eExplanations\u003c/em\u003e: CPT Commissions, t-scores; Tower, Tower Total Achievement Score.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAbbreviations\u003c/em\u003e: Mr\u0026thinsp;=\u0026thinsp;Mean Rank\u003c/p\u003e\n\u003cp\u003e*Means that represent a statistical significant difference with p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\n\u003ch2\u003eGroup differences pre-treatment\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eEF\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were significant differences between the groups in performance on tests CWIT-3 (See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), TMT-4, Category Fluency, Tower, with medium to large effect sizes, and differences remained significant when controlling for processing speed (EF contrast scores). Differences on CWIT-4, letter fluency and WCST perseverative errors approached significance with medium effect sizes. In sum, patients performed worse than controls on all measures of EF pre-ECT, and the differences were significant on all variables except for the CWIT-4 contrast score, category switching, CPT commissions and WCST categories completed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were significant differences between groups on DST, DSST and CPT omissions at T1. Effect sizes on all tests showed medium to large effects. Pre-ECT, patients performed worse than controls on all tests of attention, except the WCST failure to maintain set.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\n\u003ch2\u003eDifference in cognitive performance between groups at short-term and long-term follow ups (T2 and T3)\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003eEF\u003c/em\u003e: At T2, there were statistically significant differences between groups on the following measures: CWIT-3, CWIT-4, Letter Fluency, Category Fluency, Category Switching, TMT-4, Tower and WCST preservative errors. The effect sizes were medium to large. At T3 differences were still statistically significant between groups on these tests, in addition to CPT Commissions, with tests showing medium to large effect sizes. In sum, there were both significant short-and long-term differences between groups in all EF measures except WCST categories completed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt T2 groups were statistically significantly different on DSST with large effect sizes. At T3 this difference remained. In addition, a significant difference between groups in performance on CPT omissions manifested, with medium effect size. In sum, there were both short-term and long-term significant differences between groups in processing speed, and long-term differences between groups in inattention scores.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\n\u003ch2\u003eShort-term change in cognitive functions post-treatment (T1-T2)\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eEF\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients demonstrated a statistically significant improvement in performance on CWIT-3 from T1 to T2 with a medium to large effect (See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Controls also showed significant improvement in CWIT-3 from T1 to T2 with a medium to large effect. Also, contrast scores for CWIT-3 showed significant improvement for the patient group with a medium to large effect size. The control group approached significant improvement with a medium effect. Patients demonstrated a medium improvement on the Tower test and a possible decline in verbal fluency switching, that approached significance, which was not evident in controls. The control group showed significant improvement on CPT Commissions from T1 to T2. Patients also showed an improvement on CPT Commissions that approached significance. Finally, controls showed a significant medium sized improvement in Letter Fluency from T1 to T2. In sum, the patient group and the control group showed significant short-term improvement in Inhibition indicating practice effects in both groups. Only the control group showed significant short-term improvement in Verbal Fluency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere were no significant changes for attentional performance in the patient group from T1 to T2. The control group showed a statistically significant increase in performance on DSST from T1 to T2 with a large effect size. In sum, the control group showed short-term practice effect improvements in visual attention and processing speed, while patients showed no short-term improvement.\u003c/p\u003e\n\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\n\u003ch2\u003eChanges in cognitive functions from short-term to long-term follow-up (T2-T3)\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eEF\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients demonstrated a statistically significant improvement in performance on CWIT-4 from T2 to T3 with a medium to large effect size. Controls also demonstrated a statistically significant improvement in performance on CWIT-4 from T2 to T3 with a large effect size. There was also a significant change in CWIT-4 contrast scores for both groups. In sum, both groups showed long-term improvement in Switching, indicating practice effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients showed a statistically significant increase in performance on DST from T2 to T3 with a medium to large effect size. On DSST patients also showed a statistically significant increase from T2 to T3 with a medium to large effect size. Controls showed a statistically significant improvement in CPT omissions with a moderate effect size. In sum, the patient group showed a significant long-term improvement in auditory attention, working memory, visual attention and processing speed, while controls did not demonstrate such improvement. The control group showed significantly less long-term inattention, indicating a practice effect.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\n\u003ch2\u003eChanges from baseline to long-term follow-up (T1-T3)\u003c/h2\u003e\n\u003cp\u003e\u003cem\u003eEF\u003c/em\u003e: Patients showed a statistically significant improvement in CWIT-3 and CWIT-3 contrast scores from T1 to T3 with large effect sizes. Patients also approached significant change in CWIT-4 with a large to medium effect size. Controls demonstrated significant improvement from T1 to T3 on the following tests: CWIT-4, Letter Fluency, Tower and CPT Commissions. In sum, the patient group showed long-term improvement in inhibition as the healthy controls showed long-term practice effects on several EF measures except in inhibition measured by CWIT-3.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAttention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFrom T1 to T3 patients showed a statistically significant increase in DSST from T1 to T3 with a large effect size. The patient group showed a significant increase in WCST failure to maintain set from T1 to T3 indicating a large effect size. Healthy controls showed a statistically significant improvement on DSST from T1 to T3 with a large effect size. In sum, both groups showed significant long-term improvement in visual attention, while only the patient group showed significantly more long-term inattention (See Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e for a summary of results).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSummary of findings: Differences in Executive- and Attentional functioning and changes in patients\u0026rsquo; cognitive performance\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003ePre ECT (T1)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ePost ECT (T2)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e6 months following ECT (T3)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGroup differences (p\u0026thinsp;\u0026lt;\u0026thinsp;.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGroup differences\u003c/p\u003e\n\u003cp\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChange in patient group from T1 (p\u0026thinsp;\u0026lt;\u0026thinsp;.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGroup differences\u003c/p\u003e\n\u003cp\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChange in patient group from T1\u003c/p\u003e\n\u003cp\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;.05)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eExecutive functions\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;6/13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;10/13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;2/13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;11/13\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;2/13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInhibition\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCWIT-3 Inhibition\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCPT Commissions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCWIT-3 Contrast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.068\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eFlexibility/ Shifting\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCWIT-4 Inh/switch\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.069\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.055\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCWIT4 Contrast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.081\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCategory Switching\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.055\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTMT-4 (TMT-B)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTMT-4 Contrast\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWCST CC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWCST PE\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVerbal Fluency\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLetter Fluency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.090\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCategory Fluency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003ePlanning ability\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTower Achievement\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAttentional functioning\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;3/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;2/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;2/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;2/4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN Tests\u0026thinsp;=\u0026thinsp;2/4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eAuditory Attention Working Memory\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDigit Span Test\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eVisual attention\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProcessing speed\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDSST\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cstrong\u003eInattention\u003c/strong\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCPT Omission\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.059\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.066\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026ne;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eWCST FMS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026asymp;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e▲\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003eCC\u0026thinsp;=\u0026thinsp;Categories Completed, CPT\u0026thinsp;=\u0026thinsp;Continuous Performance Test-II, CWIT\u0026thinsp;=\u0026thinsp;Color-Word Interference Test, DSST\u0026thinsp;=\u0026thinsp;Digit Symbol Substitution Test, ECT\u0026thinsp;=\u0026thinsp;Electroconvulsive therapy, FMS\u0026thinsp;=\u0026thinsp;Failure to Maintain Set, PE\u0026thinsp;=\u0026thinsp;Perseverative Errors, WCST\u0026thinsp;=\u0026thinsp;Wisconsin Card Sorting Test, N Tests\u0026thinsp;=\u0026thinsp;number of tests in each domain significantly different between groups or improved /total number of tests, \u0026ne; significant difference between groups, ▲ significant improvement, \u0026asymp; no significant difference between groups\u0026thinsp;\u0026asymp;\u0026thinsp;no significant change in test score\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\n\u003ch2\u003eThe relation between symptoms and cognitive function\u003c/h2\u003e\n\u003cp\u003eThe bivariate correlation coefficients calculated for change scores in neuropsychological tests and change depressive symptoms did not reveal any significant results, except for inhibition measured by CWIT3 \u003cem\u003e\u0026rho;\u003c/em\u003e(\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e)\u0026thinsp;\u003cem\u003e=\u003c/em\u003e\u0026thinsp;.609, \u003cem\u003ep\u0026thinsp;=\u003c/em\u003e\u0026thinsp;.047.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study aimed to investigate short- and long-term effects of ECT on EF and attention. By exploiting the rapid antidepressant effect of ECT, changes in attentional and executive function in relation to trait/scar and state effects of depression were examined. The study found no indications of worsening general executive and attentional functions following ECT, as deficits apparent pre-treatment either persisted or improved following ECT. An improvement in specific aspects of EF and attention was evident in inhibition, visual attention, processing speed, auditory attention and working memory. However, results varied between tests within aspects for several of the executive functions and in certain aspects of attention. While patients six months after ECT reached a level of functioning comparable to healthy controls in auditory attention and working memory, impairments were still evident in visual attention, processing speed, inattention, and executive functions. Thus, findings in the present study provide support for both perspectives, with a state-related cognitive functional improvement following a significant antidepressant effect of ECT, in addition to persistent cognitive impairments that can be attributed to trait- or scar-related effects of depression.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDo patients suffering from depression have reduced executive functions and attentional capacity when compared to healthy controls pre ECT?\u003c/b\u003e \u003c/p\u003e \u003cp\u003eRegarding EF, the hypothesis with expected significant differences between groups at baseline was confirmed for most but not all measures. This is in line with meta studies of EF in MDD(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Patients demonstrated a significantly poorer ability to plan, as measured by the Tower Test. Patients showed deficits in one of the measures of inhibition (CWIT-3), while inhibition as measured by CPT commissions was not significantly poorer compared to controls, although with poorer performance showing small to medium effect size. Also, for verbal fluency, patients performed significantly worse in the category fluency condition. Patients did perform poorer than controls on letter fluency with a medium effect size, although group differences did not reach significance. Lastly, there were impairments in one measure of the aspect switching or mental flexibility (TMT-4). Differences were not significant when switching were measured with CWIT-4, although differences approached significance and showed medium effect size with patients performing worse than controls.\u003c/p\u003e \u003cp\u003eAs expected, patients showed reduced capacity in all aspects of attention when compared to healthy controls pre-ECT except in WCST failure to maintain set. This coincides with previous research pointing to impairments in various aspects of attention due to depression(\u003cspan additionalcitationids=\"CR31\" citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). However, results differed between tests for the aspect of inattention, where patients performed significantly poorer on CPT omissions compared to controls, while performance did not differ significantly on WCST failure to maintain set. One possible explanation for the differing results could be that while CPT omissions will be affected by reaction time, WCST is not and, therefore might be less affected by the reduced processing speed in patients with depression. However, Stordal et al. (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) did find impairments in the WCST condition failure to maintain set also when adjusted for psychomotor speed.\u003c/p\u003e \u003cp\u003eImpairments, defined as significant group differences, were identified for all measured aspects of attention and EF. Finding impaired attentional and executive functioning in patients aligns with previous studies on the neurocognitive profile in patients with MDD(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, finding that patients performed worse overall, but not significantly different from controls on four measures of EF, could also be explained by a small sample size and insufficient power to detect medium sized effects consistently. Also, some tests of EF are likely less sensitive to the cognitive deficits experienced in MDD(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eDo patients\u0026acute; executive and attentional functions improve shortly and longtermly (6 months) post ECT?\u003c/h2\u003e \u003cp\u003eAs hypothesized, EF and attentional capacity either improved or remained stable post-ECT. Results can be interpreted as supporting earlier findings, indicating that the domains of EF and attention are unharmed by ECT(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Separating the domains of EF and attention, in addition to discerning the respective aspects of these domains, we were able to identify some nuances adding to previous results, suggesting that some aspects of these functions improve. This was also possible due to the comparison of potential practice effects in the patient and control group.\u003c/p\u003e \u003cp\u003ePatients did demonstrate an improvement in inhibition measured by CWIT3 from T1 to T3 that was not detected in controls. However, practice effects in inhibition were evident in the control group at the short-term follow-up and this might indicate that the control group had received a ceiling effect at the long-term follow-up or could be explained by lower statistical power due to smaller sample and drop out. Moreover, the patients still underperformed at the inhibition task after six months compared to the control group. Besides inhibition, there was not found any statistically significant change in any of the other measures of EF, which is in line with predictions of the trait- and scar-hypothesis.\u003c/p\u003e \u003cp\u003eContrary to a recent meta-analysis, the present study did not find short-term decline in letter fluency(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). This could be explained by the low statistical power of the present study, but also the heterogeneity in time intervals for short term measures and patient groups included in the meta-analysis(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). However, our study found a possible a short-term decline in category switching, however this finding approaching statistical significance should be further investigated in larger studies with more statistical power.\u003c/p\u003e \u003cp\u003eThe control group demonstrated statistically significant improvements on several measures that were not found in patients. Short-term changes included significant improvement in inhibition and verbal fluency. The control group showed a significant long-term improvement in inhibition, switching, verbal fluency and planning. As the control group showed a large improvement in verbal fluency which were not present in the patient group, the results could indicate that patients have lost practice effects, which could be either due to the depressive state or the ECT.\u003c/p\u003e \u003cp\u003eIn sum, there was no decline in patients' performance on executive measurements, in addition to significant long-term improvement or practice effects in patients\u0026acute; ability to inhibit. Compared to patients, the control participants did demonstrate a greater improvement in verbal fluency, inhibition, switching and planning. This could indicate a missed practice effect for patients in measures of EF, or it could indicate a negative effect of treatment on performance. In this regard, the results do not rule out the possibility of iatrogenic effects of ECT on EF. However, the preexisting differences in most cognitive tests, in addition to the known effects of depression on neuroplasticity(\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), suggest that depression history, at least partly, could explain the relatively poor practice effects in the depression group(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This could be especially true for the current patient group undergoing ECT considering this treatment often is administered for particularly complex and severe cases of MDD.\u003c/p\u003e \u003cp\u003eRegarding visual attention and processing speed, the patient group showed no short-term improvements, but had a statistically significant long-term improvement. Results thus indicate a positive effect of the symptom recovery following ECT on these aspects of attentional functioning. However, the control group also showed a long-term significant improvement on visual attention and processing speed, which may indicate that patients' improvements can be the result of a practice effect on longitudinal measurements. Results regarding processing speed support previous findings on how this aspect of attention is affected by the presence of depressive symptoms(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), and results could therefore support the state-hypothesis. Also, a recent meta-analysis found processing speed improved following remission which also support this perspective (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Still, group differences were present at all time points also indicating a trait or scar perspective on attention. Patients demonstrated a long-term improvement in auditory attention and working memory, where the latter is in line with previous findings (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Both the groups showed significantly less long-term inattention, indicating practice effects.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAre patients' executive and attentional abilities comparable to healthy controls shortly post ECT and at 6 month follow up?\u003c/b\u003e \u003c/p\u003e \u003cp\u003eCompared to healthy controls, patients were expected to demonstrate residual impairment in both domains six months post ECT(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Comparing short- and long-term measures of EF in the two groups, control participants achieved significantly higher scores in all measured aspects of EF post-treatment. Patients performed significantly poorer compared to the control group on most EF variables at both the short- and long-term follow-up (T2 and T3).\u003c/p\u003e \u003cp\u003eThe results for attentional assessments were slightly more diverse. At the short-term follow-up (T2), results indicated comparable results for auditory attention, working memory and inattention, but not for processing speed and visual attention. Results also indicated comparable abilities for auditory attention and working memory at the long-term follow-up (T3). Significant differences were found in visual attention, processing speed and inattention at the six-month follow-up, where the patient group performed poorer than healthy controls.\u003c/p\u003e \u003cp\u003eWith some exceptions, results indicate stable differences in performance for EF, inattention, visual attention and processing speed from pre- to post-treatment. Patients have a stable tendency to score lower in these aspects when performance is compared to the performance of controls. These findings harmonize with previous research indicating that impairment seems to last beyond the depressed episode (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Such findings align with the trait- and scar hypothesis for depression. However, indications for a state-effect were also identified through findings showing that patients reached a level of functioning comparable to healthy controls on post-treatment measures in certain aspects. Results could also be influenced by MADRS scores indicating considerable residual symptoms in the patient group at follow up. Finally, since there were no tests of the cognitive functioning of the patients before their illness, the trait perspective can only be inferred, not confirmed by the current study design.\u003c/p\u003e \u003cp\u003e \u003cb\u003eWill the cognitive profile following ECT show improvement in EF and attention related to mood symptoms (state) or show pre-post persistent impairments (trait or scar)?\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe did expect to find a relation between improvement in mood symptoms and cognitive functions for both EF and attention, but the present study only suggested such relation for the EF aspect of inhibition. Finding that change in inhibition score was related to change in depressive symptoms adds to previous findings that indicate a pattern of trait-related effects of depression on inhibition (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) showing significant differences in inhibition between groups despite mood symptom load. Still, the correlation between improvement in inhibition and improvement in mood identified in the present study aligns with the state-hypothesis, predicting that inhibition improves as the depressive symptoms decrease. Alternatively, or in addition, improvements in inhibition could be related to the antidepressant effects of ECT. However, the limited statistical power of this study and the small sample showing these effects warrants careful interpretations, and there is a need to test this relation with a larger sample size. Also, the low variance in depressive scores might have an impact on the present findings as well as the potential practice effects related to findings of improvement in the healthy control group as well. Still, by inspecting the long-term improvements in attention and psychomotor speed measures along with significant symptom improvement, this might strengthen a state perspective for these functions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eStrengths, limitations and further directions\u003c/h2\u003e \u003cp\u003eThe present study has several strengths and limitations that are recommended to be considered in future research. The longitudinal design enabled monitoring of changes over time and exploring the cognitive nature of depression as well as both immediate and long-term effects of ECT. However, future studies should also include longitudinal measurements beyond six months to further investigate long-term changes. Inclusion of a healthy control group has previously been a methodological shortcoming in ECT research(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), and is included in the present study to identify deficits present pre-treatment. By including a healthy control group, we also controlled for potential practice effects and were able to differentiate between impairments attributable to treatment from impairments related to the depression per se.\u003c/p\u003e \u003cp\u003eHeterogeneity in the use of ECT in research challenges the ability to compare results and may have contributed to inconclusive or mixed findings regarding cognitive side-effects of treatment. It is not uncommon that studies and meta-analysis lack a differentiation between different ECT procedures(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). This represents a challenge when modern and older ECT practices are associated with different outcomes in cognitive function (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Consequently, standardization of ECT-procedures should be pursued. Further, there is a need for standardizing test batteries used in ECT studies, as there is great variation in the application of neurocognitive tests. To account for this, a variety of established neuropsychological tests were administered in the present study, and such cognitive tests are strongly recommended to include in routine ECT follow-up (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Also, our study indicates that some aspects of WCST are not sensitive to cognitive deficits in MDD.\u003c/p\u003e \u003cp\u003eA limitation of the present study is that it did not include any self-report measures, which may lead to an incomplete understanding of the extent of persistent or improved cognitive difficulties. Autobiographical memory loss is often of concern following ECT (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). The discrepancy between subjective and objective outcomes after ECT (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e) should be explored further and subjective measures included to provide a more comprehensive understanding of cognitive change.\u003c/p\u003e \u003cp\u003eMatching for demographic variables could be important in research on MDD (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e). In the present study, both patients and healthy controls were comprehensively examined in terms of demographic parameters. Correspondingly, the control group had statistically significant higher education and IQ, which can have influenced cognition and thus the validity of the present results. In future research, we suggest efforts are made to match demographic variables between patients and healthy controls, however this is not always indicated, e.g. when the condition being are studied influences these aspects(\u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe inclusion of patients with both bipolar and unipolar depressive disorder gives the study a broad ecological valid, and representative, sample. However, both groups consist of small samples, making subgroup comparisons difficult. In addition, the current study has a substantial amount of missing data. Late inclusion of patients and a high drop-out rate is the reason for this. As a consequence of missing data and sample size, it is possible that some group differences or changes in attentional and EF were undetected and that findings were influenced by attrition effects. Results should be interpreted accordingly. Further examination is needed to clarify how ECT and depression affect cognitive functions in patients with severe and treatment-resistant depression, in large, matched samples, with long follow-up time and tests assessing several domains of cognition. To best address potential iatrogenic effects of ECT, patients with depression matched on clinical and demographic variables could be compared on ECT if one group underwent ECT, and one did not.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eClinical implications\u003c/h2\u003e \u003cp\u003eResults from this study are useful for both practitioners and patients. Findings can contribute to providing patients with more nuanced information regarding potential side effects of ECT treatment, in addition to awareness about impairments that can be attributed to the depression itself, and that the deficits reported by patients can be influenced secondary to reduced EF and attention caused by ECT. Even after treatment, our results show lasting cognitive difficulties when compared to a healthy group. Such knowledge can be used to normalize patients' experience of cognitive impairments. Also, findings suggest that cognitive remediation interventions could be useful in this group(\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is important to acknowledge that our results are based on group-level analyses and hence cannot be used to refute the fact that a few patients may experience adverse effects following ECT(\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e). Also, it is known that autobiographical memory consistency is reduced following ECT(\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e), but this was not investigated in the present study.\u003c/p\u003e \u003cp\u003eMore detailed knowledge about side-effects of ECT as provided in this study can strengthen clinicians and patients\u0026acute; ability to make informed decisions about ECT treatment and predict risk and benefits associated with treatment. Importantly, by finding mostly positive and neutral effects of ECT on tests of EF and attention, this study may contribute to reducing the stigma associated with the treatment. Reducing stigma and clarifying side-effects could be a key factor to minimize underutilization of a treatment option that besides being lifesaving has the potential to improve patients functioning and quality of life.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, this study did not find indications of worsening of performance after ECT on either aspects of attention or executive functions in patients with depression. However, the control group showed improved performance in some aspects and this might indicate lost practice effects for the patient group. Patients demonstrated both short- and long-term improvement in several aspects of cognitive function, alluding to a possible state-related improvement following symptom relief, still with significant difference in performance compared to the control group. More specifically, patients showed significant improvement in auditory attention, working memory, visual attention, processing speed and inhibition from pre- to post measures. However, group differences identified both pre- and post ECT indicated persistent impairments in EF and some aspects of attention (visual attention, processing speed and inattention) that are interpreted as supporting a trait- or scar effect of depression on cognitive function. In conclusion, it can be inferred that the cognitive profile following ECT is differential, with some aspects of cognitive functions improving along symptom reduction, while others remain impaired related to the enduring effects of depression or inherent vulnerability traits.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eECT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eElectroconvulsive treatment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emajor depressive disorder\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMADRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMontgomery Aasberg Depression Rating Scale\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQ\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eintelligence quotient\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eD-KEFS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDelis-Kaplan Executive Function System\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eWisconsin Card Sorting Test\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eWCST\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eContinuous Performance Test\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCPT\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eColor-Word Interference Test\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCWIT\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTrail Making Test\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eTMT\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDigit Symbol Substitution Test\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDSST\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDigit Span Test\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDST\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e \u003cp\u003e Written and informed consent from participants was collected in advance of participation. All participants consented to participation in the study. The study was approved by the Regional Committee for Medical and Health Research Ethics, South East, ID: 2013/1032 ECT and neurology.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication:\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests:\u003c/h2\u003e \u003cp\u003eNone of the authors have any competing interests to declare.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding:\u003c/h2\u003e \u003cp\u003eHelse Vest (Western Norway Regional Health Authority) \u0026minus;\u0026thinsp;911986 [Oedegaard], Helse Vest (Western Norway Regional Health Authority) \u0026minus;\u0026thinsp;912238 [Oltedal]\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eEHR and \u0026Aring;H share first authorship and supervised the writing of the first draft, designed the research questions and wrote final draft of in the current paper. EHR performed and supervised analysis and creating of tables. RU and MAS wrote the first draft of the paper. performed analysis and created tables. UK, KJ\u0026Oslash; and LO helped perform the study commented and edited the manuscript. All authors approved the final paper for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe would like to acknowledge the funders, and the patients, as well as collaborating health care institutions. Finally, Leila Frid is acknowledged for her part in running the study and assessing participants. Your efforts are greatly appreciated.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials:\u003c/h2\u003e \u003cp\u003eAnonymized data will be made available per inquiry in accordance with Norwegian data protection laws.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eOtte C, Gold SM, Penninx BW, Pariante CM, Etkin A, Fava M. mfl. Major depressive disorder. 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BMC Psychiatry desember. 2020;20(1):453.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSellev\u0026aring;g K, Bartz-Johannessen CA, Oedegaard KJ, Nordenskj\u0026ouml;ld A, Mohn C. Bj\u0026oslash;rke JS, mfl. Unmasking Patient Diversity: Exploring Cognitive and Antidepressive Effects of Electroconvulsive Therapy. Eur Psychiatr 12 januar 2024;1\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemkovska M, Knittle H, Leahy J, Rasmussen JR. Subjective cognitive complaints and subjective cognition following electroconvulsive therapy for depression: A systematic review and meta-analysis. Aust N Z J Psychiatry januar. 2023;57(1):21\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Table 3","content":"\u003cp\u003eTable 3 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"ECT, short- long-term effects, longitudinal, iatrogenic effects, EF, cognitive function, attention, Treatment-resistant Depression, MDD","lastPublishedDoi":"10.21203/rs.3.rs-5019584/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5019584/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eHow cognition is influenced by electroconvulsive treatment (ECT) and major depressive disorder (MDD) is still debated. The development and etiology of neurocognitive impairment in MDD was examined by investigating the cognitive profile following ECT related to the state-, scar and trait-perspectives, with the former predicting improvements parallel with depressive symptoms, while the two latter expected persisting impairments. executive functions (EF) and attention are central to cognition and alterations in these functions could influence other domains like memory. The main aims of the present study were to examine short- and long-term effects of ECT on EF and attention in patients with major depressive disorder by exploiting the rapid antidepressant effect of this treatment.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA case-control longitudinal follow-up design was used to investigate the effects of unilateral brief-pulse ECT on EF and attention in patients with depression (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;36) compared to untreated healthy controls (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;16). EF and attention were measured pre-treatment (T1), approximately three weeks (T2) and 6 months post-treatment (T3).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe patient group showed significantly worse performance on most tests compared to healthy controls pre-treatment, and no short- or long-term worsening of EF and attention following ECT was found. Significant improvement was identified in patients\u0026rsquo; attentional capacity, processing speed and inhibition after ECT.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe present study showed that there was no cognitive worsening after ECT treatment. An improvement in several of the tests measuring inhibition, attention and processing speed was parallel to symptom reduction, with the former showing associations to symptom change, suggesting state-related effects from improved mood. Still, the patient group performed significantly worse on most measures both pre-treatment and at the short- and long- term follow-ups, indicating prevailing trait or scar effects on cognitive functions and potential lack of practice effects.\u003c/p\u003e\u003ch2\u003eClinical trial number:\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Improvement of persistent impairments in Executive Functions and Attention following Electroconvulsive therapy in a case control longitudinal follow up study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-08 09:19:07","doi":"10.21203/rs.3.rs-5019584/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-26T04:54:27+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-25T23:54:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-19T14:45:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"62283656150970674397942782153596191361","date":"2024-09-16T06:46:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74407505160358946693750627632813520625","date":"2024-09-14T17:39:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-09-14T09:55:19+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-09-13T09:22:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-13T09:05:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-12T11:04:53+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Psychiatry","date":"2024-09-02T15:39:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-psychiatry","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bpsy","sideBox":"Learn more about [BMC Psychiatry](http://bmcpsychiatry.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bpsy/default.aspx","title":"BMC Psychiatry","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99eaa10e-e7b1-4f6c-a92d-5ea95273b8e7","owner":[],"postedDate":"November 8th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-11-25T16:06:12+00:00","versionOfRecord":{"articleIdentity":"rs-5019584","link":"https://doi.org/10.1186/s12888-024-06270-5","journal":{"identity":"bmc-psychiatry","isVorOnly":false,"title":"BMC Psychiatry"},"publishedOn":"2024-11-20 15:57:20","publishedOnDateReadable":"November 20th, 2024"},"versionCreatedAt":"2024-11-08 09:19:07","video":"","vorDoi":"10.1186/s12888-024-06270-5","vorDoiUrl":"https://doi.org/10.1186/s12888-024-06270-5","workflowStages":[]},"version":"v1","identity":"rs-5019584","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5019584","identity":"rs-5019584","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}