The sensitivity of the Mini-Mental State Examination to detect objective cognitive side-effects induced by electroconvulsive therapy, results from the Dutch ECT Consortium

Dore Loef; Philip F P van Eijndhoven; Sigfried N T M Schouws; Arjen J C Slooter; Nikki Janssen; Rob M Kok; Bart P F Rutten; Eric van Exel; Didi Rhebergen; Mardien L Oudega; Roel J T Mocking; Indira Tendolkar; Annemiek Dols; Esmée Verwijk

doi:10.1016/j.bpsc.2024.08.002

The sensitivity of the Mini-Mental State Examination to detect objective cognitive side-effects induced by electroconvulsive therapy, results from the Dutch ECT Consortium

Biol Psychiatry Cogn Neurosci Neuroimaging. 2024 Aug 9:S2451-9022(24)00236-2. doi: 10.1016/j.bpsc.2024.08.002. Online ahead of print.

Authors

Affiliations

¹ Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, De Boelelaan 1117, Amsterdam, The Netherlands; Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress program, Amsterdam, The Netherlands; GGZ inGeest Mental Health Care, Amsterdam, The Netherlands. Electronic address: d.loef@ggzingeest.nl.
² Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behavior, Department of Psychiatry, Nijmegen, The Netherlands.
³ Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, De Boelelaan 1117, Amsterdam, The Netherlands; Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress program, Amsterdam, The Netherlands; GGZ inGeest Mental Health Care, Amsterdam, The Netherlands.
⁴ Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium.
⁵ Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behavior, Department of Psychiatry, Nijmegen, The Netherlands; Donders Centre for Medical Neuroscience, Department of Medical Psychology, Radboud University Medical Center, Nijmegen, The Netherlands.
⁶ Department of Old Age Psychiatry, Parnassia Psychiatric Institute, The Hague, The Netherlands.
⁷ Department of Psychiatry and Neuropsychology, School for Mental Health and Neuroscience, Maastricht University Medical Centre, Maastricht, The Netherlands.
⁸ Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, De Boelelaan 1117, Amsterdam, The Netherlands; Department of Research, GGZ Centraal Mental Health Care, Amersfoort, The Netherlands.
⁹ Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress program, Amsterdam, The Netherlands; Amsterdam UMC, University of Amsterdam, Department of Psychiatry, Amsterdam, The Netherlands.
¹⁰ Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands; Donders Institute for Brain, Cognition and Behavior, Department of Psychiatry, Nijmegen, The Netherlands; Department of Psychiatry and Psychotherapy, University Hospital Essen, Essen, Germany.
¹¹ Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Psychiatry, De Boelelaan 1117, Amsterdam, The Netherlands; Amsterdam Neuroscience, Mood, Anxiety, Psychosis, Sleep & Stress program, Amsterdam, The Netherlands; Department of Psychiatry, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
¹² University of Amsterdam, Department of Psychology, Brain and Cognition, Amsterdam, The Netherlands; Amsterdam UMC, Department of Medical Psychology, Amsterdam, The Netherlands; ECT department, Parnassia Psychiatric Institute, The Hague, The Netherlands.

PMID: 39128496
DOI: 10.1016/j.bpsc.2024.08.002

Abstract

Background: Monitoring cognitive side-effects following electroconvulsive therapy (ECT) is crucial for balancing side-effects and clinical effectiveness. Unfortunately, evidence-based guidelines on cognitive testing following ECT are lacking. A frequently used test in global ECT practice is the Mini Mental State Examination (MMSE). We examined the change of the MMSE and its performance in identifying a decline in predefined neuropsychological measures sensitive to ECT-induced cognitive changes: verbal recall and verbal fluency.

Methods: The mean MMSE scores pre- and one week post-ECT were compared using a Wilcoxon signed-rank test. The Reliable Change Index was calculated for all cognitive measures to indicate whether an individual's change score from pre- to post-ECT is considered statistically significant. The sensitivity and specificity of the MMSE were calculated.

Results: 426 patients with depression from five sites were included from the Dutch ECT Consortium. The mean MMSE increased significantly from 26.2 (SD=3.9) pre-ECT to 26.8 (SD=3.8) post-ECT (p=0.002). 36 patients (8.5%) showed a significant decline in MMSE score post-ECT. The sensitivity of the MMSE in identifying patients who experienced a significant decline in verbal recall or verbal fluency ranged from 3.6% to 11.1%. The specificity of the MMSE in identifying patients who did not experience a significant decline in verbal recall or verbal fluency ranged from 95.6% to 96.6%.

Conclusions: Given the very low sensitivity of the MMSE, we propose reconsidering the prominence of the MMSE in ECT practice and cognitive monitoring guidelines, advocating for a more comprehensive approach to assess ECT-induced cognitive changes.

Keywords: MMSE; cognition; cognitive side-effects; depression; electroconvulsive therapy; mood disorders.