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,‡§
Yee 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 for schizophrenia1–3 and mood disorders.4 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 right unilateral in Australia).5 In many
developed countries,6–9 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
term anterograde amnesia lasting for up to a few weeks23,24 and
slowing of reaction time and retrograde amnesia,22 although this
is not uniformly observed.25,26 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
method.29 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-based (age − 10%) dosing method.29 Electroconvulsive
therapy continued to be delivered using a Thymatron System IV
(Somatics, LLC) and used either a bitemporal, right unilateral
(d’Elia position30), or bifrontal electrode positioning.31 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 demonstrated
efficacy in previous studies (Phutane et al1). 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
Brief Psychiatric Rating Scale (BPRS32; subscale for psychotic
symptoms [hallucinatory behavior, suspiciousness, conceptual
disorganization, and unusual thought content] and overall scores
[which included negative and disorganized subscales]). We
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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 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).
DISCUSSION
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 patients
with schizophrenia.2
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
BT-ST, as might have been expected given the results of,1 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
stimulation46 and lesser cognitive adverse effects.47 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 al.1 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
Because these results are derived from a naturalistic real-
world sample, they must be considered preliminary until a ran-
domized controlled trial can be conducted to compare the effects
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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