ORIGINAL STUDY
Effectiveness of Electroconvulsive Therapy and
Associated Cognitive Change in Schizophrenia
A Naturalistic, Comparative Study of Treating Schizophrenia With
Electroconvulsive Therapy
Phern-Chern Tor, MBBS, DFD, MMed, FAMS,* Jiangbo Ying, MB,* New Fei Ho, PhD,*
Mingyuan Wang, BSoc,* Donel Martin, MClinNeuro, PhD,†‡ Chai Pin Ang, MBBS,* Chunzhen Tan, MD,*
Lee Shen Yap, MBChB,* Vincent John Magat Lu, MD,* Brett Simpson, MBBS, FRANZCP,ठYee
Ming Mok, MB BCh BAO, DIP, MMed, FAMS,* and Colleen Loo, MBBS, FRANZCP, MD†‡
Objective: There is limited evidence regarding the relative treatment
effectiveness and cognitive effects of different types of electroconvulsive
therapy (ECT) in schizophrenia. In this study, we sought to determine the
overall effectiveness and compare the symptomatic and cognitive out-
comes of patients with schizophrenia who received different modalities of
ECT treatment.
Methods: Patients received 1 of 4 of the following ECT modalities:
bitemporal ECT with age-based dosing, right unilateral ECT with seizure
threshold–based dosing, bitemporal ECT with seizure threshold–based
dosing, and bifrontal ECT with seizure threshold–based dosing ECT. The
Brief Psychiatric Rating Scale (BPRS) and Montreal Cognitive Assess-
ment (MoCA) were administered to 62 patients before and after the ECT
course.
Results: There was a significant improvement in both the total and psy-
chotic subscales of BPRS and MoCA scores across the patients after the
course of ECT. The global improvements in both BPRS and MoCA scores
after ECTwere not influenced by the type of ECT administered. Age-based
dosing, however, was associated with poorer memory outcomes posttreat-
ment. The overall symptomatic response rate, defined as 40% or more
reduction in the psychotic subscale of BPRS, was 64.5%. The response
rates did not significantly differ between the 4 types of ECT.
Conclusions: Our present findings suggest that an acute course of ECT
is effective in schizophrenia and may have cognitive benefits for some
patients.
Key Words: schizophrenia, electroconvulsive therapy,
electrode placement, effectiveness, cognition
(J ECT 2017;00: 00–00)
E lectroconvulsive therapy (ECT) is a safe and effective treat-ment
1–3 4
for schizophrenia and mood disorders. However, usage of ECT
around the world is highly variable, both in indi-cation for ECT and
type of ECT administered (eg, commonly bitemporal in Europe and
5 6–9
right unilateral in Australia). In many developed countries, ECT is
primarily used for the treatment of
From the *General Psychiatry, Institute of Mental Health, Buangkok View,
Singapore; †Black Dog Institute, Randwick; ‡School of Psychiatry,
University of New South Wales, Sydney; and §Older Adult Mental Health
Service, St George Hospital, Kogarah, New South Wales, Australia.
Received for publication February 4, 2017; accepted April 3, 2017. Reprints:
Phern Chern Tor, MBBS, DFD, MMed, FAMS, General Psychiatry,
Institute of Mental Health, 10 Buangkok View, Buangkok Green Medical
Park, 539747, Singapore (e‐mail: phern_chern_tor@imh.com.sg).
The authors have no conflicts of interest or financial disclosures to report.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF
versions of this article on the journal’s Web site (www.ectjournal.com).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
DOI: 10.1097/YCT.0000000000000422
Journal of ECT • Volume 00, Number 00, Month 2017
Copyright © 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
depression, whereas in Asia, it is primarily used for the
treatment of psychotic disorders.10–13
Although there is an evidence base for the use of various types
of ECT for depression14–17 (bitemporal, bifrontal, right uni-lateral, and
ultrabrief right unilateral), evidence regarding the relative efficacy and
cognitive profile of different types of ECT in schizophrenia draws
mostly from reports decades ago and is scant. 18–21 A Cochrane review
of ECT in schizophrenia concluded that ECT is efficacious in the
acute and continuation treatment of schizophrenia in combination with
antipsychotics, and that bilat-eral and unilateral ECT are equally
efficacious, with possible transient cognitive adverse effects. 3 A more
recent study of schizophrenia suggests superior efficacy and cognitive
adverse effect profile of bifrontal over bitemporal ECT. 1 In
depression, ultrabrief right unilateral (RUL) ECT demonstrates similar
efficacy to brief pulse RUL ECT,17 but with reduced cognitive adverse
ef-fects, addressing the main drawback of ECT.22 Certain forms of
ECT (sine wave, bitemporal, high dose) are known to cause short
23,24
term anterograde amnesia lasting for up to a few weeks and
22
slowing of reaction time and retrograde amnesia, although this
25,26
is not uniformly observed. Little is known about the symp-
tomatic response and cognitive effects of varying ECT pulse
width in schizophrenia.
To guide practice and optimize ECT treatment in schizo-phrenia,
studies on the effectiveness and cognitive outcomes of age-based
versus empirical seizure threshold–based dosing and different
electrode placements are needed. Hence in the present study, we
aimed to examine the effectiveness and cognitive out-comes of ECT
treatment of schizophrenia in a real-world hospital setting. We first
sought to examine the change in symptomatic response before and
after the course of ECT across patients with schizophrenia. We then
examined whether the response and cognitive outcomes differed
among the 4 ECT modalities. Electroconvulsive therapy was given
using an age-based dosing approach for the past 30 years at the
hospital, until ECT services were revamped in 2015 to move from this
one-size-fits-all approach to an individualized seizure threshold–based
approach27,28 with a range of electrode placements (bitemporal,
bifrontal, right unilat-eral) and pulse parameters (0.5 or 1 millisecond
pulse width).
MATERIALS AND METHODS
The Singapore Institute of Mental Health (IMH) is the only
tertiary psychiatric hospital in Singapore, and it has 1900 inpatient
beds, approximately 40,000 outpatients, and treats approximately
80% of the national load of patients with schizophrenia. Clini-cal
records in IMH indicate that ECT is prescribed primarily for
schizophrenia (47%) with schizoaffective disorder (20.3%),
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Tor et al
depression (20.4%), and mania (6.8%) being the other major
indications.
Patients were referred to the ECT service by psychiatrists who
diagnosed schizophrenia using clinical assessments based on
Diagnostic and Statistical Manual of Mental Disorders, Fourth/Fifth
Edition (DSM-IV/DSM-V) or International Statistical Classification
of Diseases, 10th Revision (ICD-10) criteria. Patients were typically
referred for treatment of psychotic symptoms, which had not
responded adequately to pharmacological treatment and as a result,
were too unwell for discharge back to the community. The number of
sessions of ECT prescribed was determined by the treating psychiatrist
based on the patient's clinical response. Data from patients with
schizoaffective disorder or substance-induced psychosis were not
examined.
Electroconvulsive Therapy
Before 2015, standard ECT treatment at IMH consisted of
bitemporal ECT administered 3 times per week, using disposable
adhesive type electrodes; dosing was determined by the refer-ring
psychiatrist using an “age minus 10% (50.4 mC)” dosing
29
method. Increases in dosing were made based on reductions in
seizure duration or electroencephalogram quality, which usu-ally
meant a 5% to 10% machine power increase in energy levels.
A revamp of ECT services in 2015 consisted of several major
changes. Individualized dosing based on each patient's empiri-
cally determined seizure threshold was used, rather than the age-
29
based (age − 10%) dosing method. Electroconvulsive therapy
continued to be delivered using a Thymatron System IV
(Somatics, LLC) and used either a bitemporal, right unilateral
30 31
(d’Elia position ), or bifrontal electrode positioning. Bitemporal
ECT was delivered at 0.5 millisecond pulse width, and Bifrontal
ECTwas delivered at 1.0 millisecond pulse width, both at 1.5
times seizure threshold. The longer pulse width was selected for
bifrontal ECT compared with bitemporal ECT, because of
1
demonstrated efficacy in previous studies (Phutane et al ). Right
unilateral ECT was delivered at 0.5 millisecond pulse width at 5
times seizure threshold. The anesthetic used was propofol, which
was dosed at 1 mg/kg.
After the revamp in 2015, the type of ECT treatment was
changed, although at any one time the default treatment protocol was
1 type of ECT for all patients. In the first change, the default type of
ECT was switched from bitemporal age-based dosage (BT-AB; 0.5
millisecond pulse width) to right unilateral seizure threshold–based
dosage (RUL-ST; 0.5 millisecond pulse width) due to the well-
established cognitive benefits of RUL-ST over bitemporal ECT. 14 An
interim analysis of effectiveness showed a trend for RUL-ST to be less
effective than BT-AB ECT. Hence, the ECT modality for
schizophrenia was changed to bitemporal seizure threshold–based
dosing (BT-ST; 0.5 millisecond pulse width). Subsequently, the ECT
modality was changed to bifrontal seizure threshold–based dosing
(BF-ST; 1.0 millisecond pulse width) after the team became aware of
a recent trial suggesting superiority of BF-ST over BT-ST in
schizophrenia.1 Data were reported from December 2014 to May
2016, and each type of ECT was the default protocol at the hospital for
approximately 4 months.
Outcome Measures
During the study, ratings (symptom and cognitive) were per-
formed at 1 to 2 days before and 1 to 2 days after the acute course
of ECT. The primary effectiveness outcome was assessed by the
32
Brief Psychiatric Rating Scale (BPRS ; subscale for psychotic
symptoms [hallucinatory behavior, suspiciousness, conceptual
disorganization, and unusual thought content] and overall scores
[which included negative and disorganized subscales]). We
2 www.ectjournal.com
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Journal of ECT • Volume 00, Number 00, Month 2017
examined 2 outcomes for symptomatic response, as defined by
(1) change in BPRS scores pre- and post-ECT across the patients
and (2) the proportion of patients who showed an improvement of
40% or more from pretreatment scores based on the psychotic
symptom subscale.2,33,34 The primary cognitive outcome was
performance on the Montreal Cognitive Assessment (MoCA
Singaporean versions of the MoCA35,36 in the local languages
[English, Chinese, Malay, and Tamil] were used). Alternate
forms of the English MoCA forms were used for post-ECT
testing. We examined the change in total MoCA scores from
pre- to post-ECT. Changes in anterograde memory were
additionally reported using the MoCA delayed recall subtest.
The BPRS ratings were completed by ECT medical officers
who underwent rating training using standardized training videos
under the supervision of P.C.T. Intraclass correlation, as defined
by (MSrater − MSerror)/[MSrater + (average number of patients per
rater − 1)*MSerror], between the BPRS raters was 0.77, where MS
indicates mean square. The MoCA was administered by
ECT nurses. These nurses were trained by P.C.T and D.M., a
registered neuropsychologist.
The following baseline clinical and demographic variables were
extracted from the electronic patient records: type of ECT (BT-AB,
RUL-ST, BT-ST, and BF-ST), initial seizure threshold, daily dose of
concurrent antipsychotic treatment (expressed as chlorpromazine
equivalents) given during ECT,37 lifetime duration of illness (months),
age, sex, and post-ECT MoCA and BPRS scores. The duration of
current episode of schizophrenia is known to cor-relate with response
to ECT38 but was not available for analysis.
Ethics approval for data access, analysis, and report was
ob-tained from the local institutional research ethics board.
Statistics
To test for differences in clinical and demographic
baseline data between the groups receiving different types of
ECT, analyses of variance was performed.
Mixed analysis of covariance (ANCOVA) examined (1) whether
completing an ECT course affected symptom (BPRS scores) or
cognitive outcomes (MoCA scores) and (2) whether the change in
outcomes differed depending on the type of ECT administered (BT-
AB, RUL-ST, BT-ST, and BF-ST). Between-subjects factor was ECT
type (BT-AB, RUL-ST, BT-ST, and BF-ST) and within-subjects factor
was time (pre-ECT and post-ECT). Covariates were age, sex, duration
of illness, antipsychotic dose, and number of ECT sessions. For
analysis of MoCA scores, post-ECT BPRS was an additional
covariate. Where the ANCOVAs yielded signif-icant results, follow-
up tests examined where the between-group differences occurred.
Paired-samples t tests also examined changes in symptom and
cognitive outcomes across the course of ECT, within each type of
ECT modality. The proportion of patients in each ECT group who had
40% or more improvement in BPRS psychotic subscale (“responders”)
was compared using a χ2 test. Only available data were analyzed, and
missing data was not imputed.
Significance was set at a threshold of P value less than
0.05, and all analyses were completed using the Statistical
Program for Social Sciences Version 14 (SPSS; Chicago, IL).
RESULTS
Patient and Treatment Characteristics
Of a total of 99 patients treated during the study period, 62
patients were included in the final analysis because they had complete
pre- and post-ECT BPRS data. There were no statistically significant
differences in age, sex, duration of illness, chlorproma-zine equivalent
dosage, number of ECT sessions, or baseline BPRS
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Journal of ECT • Volume 00, Number 00, Month 2017 ECT in Schizophrenia: A Naturalistic Study

between patients who received the different types of ECT DISCUSSION

either for the total sample (99 patients) (Supplementary Table
1, http://links. lww.com/JECT/A58), or those with complete
data (62 patients) (Table 1). Analyses were subsequently
restricted to patients who had complete pre- and post-ECT
BPRS data. Patients re-ceiving RUL-ST received fewer ECT
treatments than patients receiving BF-ST.
Effectiveness
A significant main effect of time was found, with the overall
estimate for the post-ECT BPRS scores (adjusted mean = 32.06)
being significantly lower than the pre-ECT BPRS scores (adjusted
mean = 45.34). There was no main effect of ECT type (F [3, 53] =
1.64, P = 0.19, η2 = 0.085), and no interaction between time and
ECT type (F [3, 53] = 0.422, P = 0.738, η2 = 0.023). Paired
samples t test showed that ECT significantly improved BPRS total
score and psychotic subscale score for all 4 types of ECT (Table
2). A total of 64.5% of patients showed 40% reduction of BPRS
psychotic subscale on average within 10 sessions of ECT (or
approximately 3.5 weeks of treatment), and the response rates did
not significantly differ between the 4 types of ECT.
Cognitive Outcomes
The mixed ANCOVA revealed a significant main effect of
time (F [1, 38] = 9.625, P = 0.04, η2 = 0.202), with the overall es-
timate for the post-ECT MoCA scores (adjusted mean = 20.91)
being significantly higher than the pre-ECT MoCA scores (ad-
justed mean = 16.94). There was no main effect of ECT type (F
[3, 38] = 2.045, P = 0.124, η2 = 0.139), and no interaction be-
tween time and ECT type (F [3, 38] = 0.339, P = 0.797, η2 =
0.026). Paired samples t test showed that ECT significantly
improved MoCA scores in the BT-ST group. In contrast, in the
BT-AB group, there was a significant decrease in anterograde
memory as assessed by the delayed recall subscale at post-ECT
from 37.6 % (SD, 38.6) to 11.8% (SD, 22.4; P < 0.05; Table 3).
This retrospective analysis of the effect of ECT in schizo-
phrenia in a real world clinical setting showed that ECT was
an ef-fective treatment with rapid onset of action for
schizophrenia, decreasing symptom burden. Different ECT
modalities were equally effective in eliciting symptomatic
improvement, and there was indication of global cognitive
improvement in some patients. Age-based dosing, however,
was associated with poorer memory outcomes posttreatment.
To our knowledge, this is the first report of the comparative
effectiveness of bitemporal ECT (aged-based and seizure
threshold– based, 0.5 millisecond pulse width), bifrontal ECT (1.0
millisecond pulse width) and right unilateral ECT (0.5 millisecond
pulse width) and demonstrates the equal effectiveness of these
different modalities of ECT in schizophrenia. Almost two thirds of
the patients re-sponded to ECT, which is comparable with a recent
study that showed a 50% response rate in clozapine-resistant
2
patients with schizophrenia.
Contrary to the literature assessing cognitive adverse effects of
ECT in depression, we found an improvement of MoCA scores after
ECT, which is evident across all 4 ECT types. The finding of
equivalent cognitive gains with RUL-ST ECT as compared with BT-
ST is unexpected in view of the established cognitive superior-ity of
RUL-ST ECT compared with BT-ST.39–41 However, these studies
were conducted in depressed patients and based on com-parisons of
RUL and BT ECT given with a 1.0-millisecond pulse width. The
existing literature comparing RUL and BT electrode placement in
schizophrenia18–21 did not suggest significant differ-ences in cognitive
outcomes, but this may have been because of the older type of ECT
used (sine-wave ECT) and lack of standard-ized cognitive assessment.
Our differing results may therefore re-flect the different patient
population treated, that is RUL ECT may not have superior cognitive
outcomes in patients with schizophre-nia, which is plausible given
that schizophrenia and depression differ in the profile of cognitive
deficits.42–45 Furthermore, it is possible that use of a 0.5-millisecond
pulse width, which results in more focal stimulation, 46 mitigated the
cognitive adverse effects typically associated with bitemporal
stimulation, such that the

TABLE 1. Patient Demographic, Clinical, and Treatment Variables for the Sample by Type of ECT

Overall (N = 62), BT-AB (n = 25), RUL-ST (n = 15), BT-ST (n = 11), BF-ST (n = 11),
mean (SD) mean (SD) mean (SD) mean (SD) mean (SD) P*
Age, y 43.74 (14.02) 47.04 (10.82) 43.93 (14.84) 39.91 (14.92) 39.82 (18.07) 0.388
Age range, y 15–69 20–65 21–69 19–66 15–68 NA
Sex 0.588
Male, n (%) 26 (41.9) 8 (32.0) 8 (53.3) 5 (45.5) 5 (45.5)
Female, n (%) 36 (58.1) 17 (68.0) 7 (46.7) 6 (54.5) 6 (54.5)
Duration of illness, mo 112.7 (90.7) 112.6 (87.8) 102.4 (78.1) 120.8 (124.2) 118.9 (86.5) 0.956
CPZ equivalent, mg 670.5 (436.3) 826.5 (575.9) 574.4 (314.9) 584.8 (234.9) 532.7 (259.4) 0.140
No. ECT 9.8 (3.4) 9.5 (3.4) 8.0 (3.3)† 11.3 (1.9) 11.6 (3.8)† 0.021
Initial ECT seizure threshold 19.0 (15.8) NA 9.6 (3.1)† 17.2 (7.9)‡ 33.2 (20.6)†‡ 0.001
(% machine energy)
Initial ECT dosage (% machine energy) 42.0 (21.9) 39.5 (18.3) 48.7 (10.9)† 27.8 (10.9)†‡ 50.0 (38.3)‡ 0.048
Final ECT dosage (% machine energy) 53.5 (24.1) 51.9 (21.5) 59.7 (18.0) 33.3 (12.9) 59.1 (34.9) 0.116
Propofol dosage (mg) 55.4 (11.9) 52.7 (9.4) 55.7 (8.6) 62.2 (19.2) 54.6 (12.1) 0.249
Suxamathonium dosage, mg 29.5 (10.2) 29.5 (9.9) 28.7 (9.5) 35.0 (15.0) 25.9 (4.9) 0.253

*Comparisons between different types of ECT in patients with complete data.

†‡Between-group differences: items marked with the same symbols are statistically different from each other at P = 0.05.
CPZ indicates chlorpromazine.

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Tor et al Journal of ECT • Volume 00, Number 00, Month 2017

TABLE 2. Brief Psychiatric Rating Scale Scores Pre-/Post-ECT by ECT Type

Overall (N = 62), BT-AB (n = 25), RUL-ST (n = 15), BT-ST (n = 11), BF-ST (n = 11)
mean (SD) mean (SD) mean (SD) mean (SD) M (SD)
Pre-ECT BPRS 45.7 (11.8) 47.4 (12.8) 44.1 (11.4) 42.4 (12.2) 47.3 (10.1)
Post-ECT BPRS 31.7 (8.1)* 32.0 (7.6)* 29.2 (8.0)* 29.4 (4.1)* 36.9 (10.7)*
Improvement in BPRS 13.9 (13.6) 15.4 (13.2) 14.9 (14.9) 13.0 (12.1) 10.4 (15.4)
Pre-ECT psychotic subscale 10.7 (6.4) 10.0 (6.5) 10.9 (6.1) 10.5 (6.3) 12.0 (7.1)
Post-ECT psychotic subscale 5.3 (4.1)* 4.9 (2.8)* 5.3 (4.5)* 4.8 (3.6)* 6.8 (6.1)*
Response to ECT (40% improvement)† 40 (64.5%) 15 (60%) 10 (66.7%) 8 (72.7%) 7 (63.6%)
Response to ECT (20% improvement)‡ 47 (75.8%) 19 (76%) 12 (80%) 8 (72.7%) 8 (72.7%)
Pre-ECT Depression subscale 5.5 (5.4) 5.4 (6.9) 6.3 (4.4) 4.9 (4.2) 5.4 (4.3)
Post-ECT depression subscale 3.7 (2.7)* 3.0 (2.3)* 4.5 (2.4) 3.1 (1.8) 4.7 (4.2)
Pre-ECT negative subscale 8.9 (4.1) 9.6 (4.0) 8.6 (4.1) 8.6 (4.5) 7.8 (4.0)
Post-ECT negative subscale 6.2 (2.7) 6.9 (2.8)* 5.1 (2.3)* 5.5 (1.4) 7.1 (3.3)
Pre-ECT paranoid subscale 4.2 (1.5) 4.7 (2.5) 3.8 (1.9) 4.2 (1.8) 3.5 (1.8)
Post-ECT paranoid subscale 2.5 (1.5) 2.6 (1.7)* 2.5 (1.4)* 1.9 (0.7)* 2.9 (1.6)
Pre-ECT mania subscale 4.7 (2.1) 4.9 (2.4) 4.7 (1.9) 4.3 (1.7) 4.6 (2.2)
Post-ECT mania subscale 3.5 (1.4)* 3.5 (1.7)* 3.7 (1.7) 3.1 (0.3) 3.5 (0.9)

*Post-ECT scores that were statistically significantly different from pre-ECT scores within the same ECT group at P = 0.05.
†40% decrease in psychotic subscale.
‡20% decrease in psychotic subscale.

cognitive advantage of RUL ECT was no longer apparent. An-
other consideration is whether the equivalence of cognitive out-
comes was observed because BT-ST ECT was more effective,
with cognitive improvements associated with symptom improve-
ment leading to overall superior outcomes. However, results do
not support this interpretation, because there was no difference in
symptom efficacy between RUL-ST and BT-ST ECT.
The lack of superiority in cognitive outcomes of BF-ST over
1
BT-ST, as might have been expected given the results of, is most
likely explained by the longer pulse width used for BF-ST (1.0
millisecond) compared with BT-ST (0.5 millisecond) in this study.
Shorter pulse widths potentially allow for more focused
46 47
stimulation and lesser cognitive adverse effects. On the other
hand, one may have expected greater symptom reduction with BF-
ST compared with BT-ST given the previous results of Phutane et
1
al. The reasons for this discrepancy are not clear, and may reflect
a lack of power in this study to detect differences.
There are several limitations to this naturalistic study, the
most important being that data on outcomes of the 4 types of ECT
studied were collected in sequential cohorts. Notwithstand-ing, we
note that there was no selection bias for the type of ECT received,
as at any 1 point in time only 1 type of ECT was used to treat
schizophrenia for all patients, the same small team of doctors and
nurses conducted the ECT and assessments across
the 4 periods, there was no demographic difference between the
patients receiving the 4 types of ECT, and the cohorts of patients
assigned to different types of ECT were from the same referral base
and treated relatively closely in time (over a 17-month period).
Nevertheless, there could have been a positive rater bias as the raters
were aware that the patients were receiving ECT. Another major
limitation is that because of incomplete longitudinal data, the sample
size for each type of ECT was small with just over 10 patients in some
groups, which means that our study may have been underpowered for
detecting differences between the 4 types of ECT in symptomatic and
cognitive outcomes. Information on years of education for subjects
was not available and could not be included as a covariate. Further
studies, ideally randomized controlled trials of different ECT
modalities with a larger sample size, will be required to substantiate
our findings.
CONCLUSIONS
In conclusion, ECT is an effective treatment for treatment-
resistant schizophrenia, resulting in symptomatic improvement
and global cognitive benefits in some patients. In this study, there
was no difference in outcomes between the 4 types of ECT
assessed. Almost two thirds of patients with schizophrenia
responded to ECT after approximately 10 treatments.

TABLE 3. Cognitive Outcomes Pre-/Post-ECT by ECT Type

Overall (n = 48), BT-AB (n = 17), RUL-ST (n = 10), BT-ST (n = 10), BF-ST (n = 11),
mean (SD) mean (SD) mean (SD) mean (SD) mean (SD)
Pre-ECT MoCA (n = 48) 16.8 (9.1) 15.9 (7.9) 16.2 (9.0) 16.3 (11.0) 19.5 (10.0)
Post-ECT MoCA 20.7 (6.0)* 17.5 (3.6) 18.8 (8.5) 24.0 (5.0)* 24.5 (3.3)
Improvement in MoCA post-ECT 3.9 (9.2) 1.5 (7.8) 2.6 (9.4) 7.7 (9.3) 5.0 (10.7)
Pre-ECT recall (MoCA) 2.20 (2.09) 1.88 (1.93) 1.81 (2.09) 2.63 (2.13) 2.80 (2.44)
Post-ECT recall (MoCA) 1.89 (1.96) 0.59 (1.12)* 1.80 (2.10) 3.25 (1.39) 3.10 (2.02)
*Post-ECT scores that were statistically significantly different from pre-ECT scores within the same ECT group at P = 0.05.

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Journal of ECT • Volume 00, Number 00, Month 2017 ECT in Schizophrenia: A Naturalistic Study
19. Wessels WH. A comparative study of the efficacy of bilateral and
unilateral electroconvulsive therapy with thioridazine in acute
Because these results are derived from a naturalistic real- schizophrenia. S Afr Med J. 1972;46:890–892.
world sample, they must be considered preliminary until a ran-
domized controlled trial can be conducted to compare the effects © 2017 Wolters Kluwer Health, Inc. All rights reserved.
of different ECT modalities on cognitive and symptom outcomes
in schizophrenia. While awaiting such results, it seems prudent to
choose the type of ECT for schizophrenia based on the patient's
treatment needs. Patients with poorer pretreatment cognitive func-
tioning might best avoid BT-AB ECT.

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