Cognitive rehabilitation: assessment ...

flr/vallcas ill Psyc1liat,·ic Traatlllallt (2007), vol. 13, 90-100 doi: 1O.1192/apt.bp.106.002899

Cognitive rehabilitation: assessmentand treatment of persistent memoryimpairments following ECTMaeve A. Mangaoang & Jim V. Lucey

Abstract Few tests adaress the types of memory problem cOII}Illonly reported after electroconVul~vetherapy(ECT). Here, we focus:on the.. importance of neuropsYQ!ological assessment in EGT-treated. patientsand describe a number of tasks that may be useful in measuring the everyday memory problems ofsuch patients with ongoing memory difficulties. At the.time'of-writing, no attempts have been made

':"-to-renabilitate patients"Wh6 expenence p,eISistent aaveEe cogmtive effects, but cliriicians shoUld-beaware ofthe potential beneficial role of cbgnitive rehabilitation in the trea~ent and management ofthese effects.

III Q reLeut issue ofAPT. Robertson & Pryor (2006) drew IltleuJiot' 10a numbt:r of issue:; regarding lI,C nSSt'SSIIICllf ojcognilWeftmctiD11 inpatients I!m/cd witll r1cctrocollul/IsiilC lllcrnpy (ECT). I" parliclIlar,flll!Y higlzlighkd tlZI! paucity of tests til/It an: sensitive and relLwlltfo file speCifiC mC/Ilory problems commonly reported after ECT.Here. Mangnoang & Lucey rdurn to this problelll, discllssing1lt:lIropsyc1/(Jlogicn/ assessme/lt ill Ecr·treatrn patients.

Electroconvulsive therapy (ECT) has been used formany years, but it remains one of the most contro­versial psychiatric treatments. In recent years, aconsiderable amount of research has attempted tohighlight the efficacy and safety of EO', in addi­tion' to emphasising the overall improvements incurrent EO' techniques, equipment and standards(Shanna, 2001; Chung, 2002; UKEO' Review Group,2003; Prudic el aI, 2004). However, there also exists agrowing body of research consistently reporting theadverse cognitive and psychological consequences ofEO'among a substantial minority of patients Gohn­stone, 1999; Service User Research Enterprise, 2002;Koopowitz at aI, 2003; Rose al 01,2003; Scott, 2005).

Although discrepancies exist bet\'veen c1inician­led or hospital-based studies and tl,ose undertakenin collaboration with patients regarding the natureand extent of adverse side-effects, there is a gen­eral consensus that memory loss (Box 1) is the mostfrequently and consistently reported side-effect fol­lowing EO' (Rose et aI, 2003). There have been manyconflicting accounts of the severity and duration ofthe memory and other cognitive d ifficul ties (Weeks

at aI, 1980;Squire cl 01, 1981;Templer &Veleber, 1982;Squire &Slater, 1983; Lisanby ct aI, 2000; Brodatyelal,2000), but to date there has been a distinct lack of rou­tine neuropsychological assessment of individualsreceiving EO' at any stage during their treatinent.

Designing an assessment battery that is sensitive tothe nature of the everyday problems experienced bypatients with memory and/or cognitive disability ischallenging, and standard neuropsychological testsmay not adequately reflect the leveis of impairmentexperienced by patients on a daily basis (Robertson& Pryor, 2006). Thus, the use of novel, personallyrelevantmemory tasks such as those described belowmay be warranted.

Furthermore, no attempts have been made toprovide any form of memory rehabilitation orcognitive retraining to patients who experiencepersistent memory and other cognitive problemsin these areas following ECT. Here we argue thatcognitive rehabilitation could be offered to suchpatients as a means of addressing these difficultiesin a constructive way.

The importance of assessment

What is striking from the literature in this area isthe lack of routine, formal assessment of patients'neuropsychological performance following a COliISeof EO', despite the long-known risk to memory

Mac\'~M:mgaoang is ares~ psycholob'ist at St Patrick's Hospital (St Patrick's Hospital. PO Box 136,James's Street, Dublin a.Ireland.Email: ITh"Ulg<[email protected])andaresearchassociateattheTrinityCollegeInstituteuf Neuroscience. Her intcrest in cognitive rehabilitationstcms hom her current research on electroconvulsive therapy (ECT) as a treabnent for major depressive disorder and pre\::ious work ine.xperimental nellropsydlology among patients with temporal lobe epilepsy. Jim Lucey is a cOn5ullant psychiatrist ilnd Head of Ule ECfOepaItOlcot at St Patrick's Hospitnl. He also has a special interest in the treabnent of obsessi\'e-compulsive disorder.

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functioning (Squire & Chace, 1975; 5quire et aI, 1975;Freeman et aI, 1980; Squire & Slater, 1983; Robertson& Pryor, 2006). Furthermore, the lack of consistencyin the types of measures used to assess patients hasmade It difficult to clarify the extent and durationof the reported cognitive problems and the impactthey may have on the individual's overall qualityof life and sense of self.

in Ireland, for example, there is no publishedresearch on the long-term effects olECT on cognitivefunctioning among Irish patients. The failure toconduct such assessments means that there maybe a significant delay in detecting patients whohave experienced a marked decline in memoryfunction.

Guidelines

The importance ofassessing and monitoring patients'cognitive function throughout their treatment hasbeen recognised in guidelines on the commissioningof ECT services within the National Health Service(NHS) (Royal College of Psychiatrists, 1995, 1999),and the ECTAccreditationService (ECTAccreditationService, 2005) includes assessment and monitoringof cognitive function as standards required foraccreditation of a clinic. However, there has been arelative neglect to include such measures in routineclinical practice. It appears that even when they havebeen explicitly recommended (Freerruin et aI, 1980;Salford Community Health Council, 1998 ; RoyalCoilege of Psychiatrists, 2005) patients who reportpersistent memory loss have notbeen systematicallyfollowed-up or referred for neuropsychologicalassessment. As aresult, theirprogress or deteriorationover time in terms of cognitive performance has notbeen monitored.

Monitoringpatients' self-reports of adverse side­effeds to ECT has also been recommended by theRoyal Coilege of Psychiatrists (1995,2005) and theNational Institute for Clinical Exceilence (NICE,2003). Benbow & Crentsil (2004) have shown theimpo.rtance of measuring such experiences duringtreatment, as it allowed the ECT staff to take im­mediate action to try to relieve the problems. Forinstance, ifpatients reported persistent confusion ormemory difficulties, staffcould change from bilateralto unilateral ECT or increase the interval betweentreatments.

LOllger-term implicatiolls

The failure to adequately provide neuropsycho­logical assessments to patients receiving ECTmeansthat the impact of additional, subsequent episodes ofdepression and/or fuhlre courses of ECT on overallcognitive functioning remains lUlknown (Robertson

Post-ECT cognitive impairment

& Pryor, 2006). Establishing a baseline of functioningbefore an individual's first ECT treaimentis extremelyimportant in terms of its association with 'cognitivereserve'. This concept refers to individual differencesin factors such as education and occupation! whichmay be protective against ECT's adverse effects onmemory functioning (Legendre et aI, 2003).

The Society for Cognitive Rehabilitation (SCR;Malia et al! 2004) recommends that a combinationof standard and novel tasks to assess current cog­nitive status should be administered to patients.Objective and subjective self-report questionnairesand collateral information from family or caregiversshould be used, and the assessment battery shouldprovide sufficient information to fonn hypothesesabout the underlying cognitive impairments anddeficits that interfere with the individual's cognitivefunctioning. These recommendations concur withRobertson & Pryor's (2006) proposal that ECT­treated patients who report ongoing memory dis­ability should be referred for neuropsychologicalassessment. The purpose of this is both to detenninetheir general cognitive abilities and to measurespecific cognitive functions! such as attention! con­centration and information processing, that maybe related to memory functioning in everyday life(Ponds & Hendriks, 2006).

Makillg lise of assessments results

Rather than merely describing problems, the resultsof neuropsychological assessments should be ex­plained in terms that the patient can understand andexplicitly related back to the functional problemsthat have been identified (Mateer et aI, 2005). Theyshould be interpreted in a holistic way that takesaccount of the individual's personality and emo­tional characteristics and used to inform decisionsabout preparing a suitable rehabilitation programme(Malia et aI, 2004).

Neuropsychological assessment ofmemory

Thereare many!actors to consider in theneuropsycho­logical assessment of patients receiving ECT. Theseinclude the selection or development of appropriatetesting materials, the timing of testing sessions(Robertson & Pryor, 2006) and the effects of factorssuch as mood! metamemory and memory self­efficacy on performance (Mateer et aI, 2005; Ponds& Hendriks, 2006). Additional problems, such aslimited access to neuropsychology services! financialand time constraints! may have an impact on thenumber and frequency of assessment sessions thatcan be undertaken.

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Design of appl"Opriate tests

Although Robertson & Pryor (2006) recommend thatpatienls who havehad ECfshould be assessed withthe kind of neuropsychological tests that are useQfor patients with known or suspected brain injury,they acknowledge some of the problems associatedwith these traditional, standardised tasks. The mair)challenge appears to be designing tests that are sensi­tive to the memory and other cognitive demandsplaced on patienls in their everyday lives. This taskis made even more difficult by the realisation thatpatients with memory disability may not be able togive reliable seli-reports of their memory functioning(Cronholm & Ottosson, 1963; Roberlson & Pryor,2006). Rose el al (2003) note thatneuropsychologicalassessment of the extent of memory loss in ECfpatients has tended to focus on the ability to formnew memories (anterogradememory, Box 1),whereaspatienls have commonly reported the loss of auto­biographical memory (retrograde amnesia, Box 1)following ECf (Coleman elaI, 1996;Peretti el aI, 1996;Donahue, 2000). However, loss of autobiographicalmemory does not appear to have been adequatelyinvestigated (Robertson & Pryor, 2006). Furthermore,alternative versions of tesls maybe required to reducepractice effects over repeated assessments.

Box 1 lMenfory

Aulobiog,ap;licalmemon; ·Store of knowledge'of past experiences and personal facts of one'slife

Episodicmemory Storeofpersonalexperienc~s

that are tied tf' par~cular times and places

Semantic memon; Memory for meanings andgeperal (impersonal) facls

Topographical memory The ability to orient.oneself in- a familiar .environment as well asto learn and remember the layout of a newenvironment

Anjerograde amnesia. The loss of the ability toform new memories

Retrograde amnesia 'The loss of autobiogra­phical memory for the period before a certainevent, e.g.ECf ..

Long-tenn memory TIl~ part of the memorysystem where informationis stored over long'periods of time or indefinitely

SIwrf,ferm memory . The part of the systemwhere information' is stored very briefly(about 30 s) ,: _

Timing of testing

As mentioned above, encouraging patients whoare undergoing a course of ECT to give self-reportsof any adverse side-effects can be beneficial interms of allowing staff to take immediate actions toreduce or relieve these effects (Benbow & Crenlsil,2004). However, in many studies the prematureassessment of memory and overall cognitive func­tioning foilowing ECf has led to inaccuracies andunderestimations ofpatients' impairment (Squire &Slater, 1983; Weiner el 01, 1986; Coleman ef 01,1996;Peretti el aI, 1996; Donahue, 2000; Rogers et aI, 2002;Robertson & Pryor, 2006). It may take a number ofmonths for patients to gain a more stable view ofpermanent changes in their memory and cognition(Weiner ef 01, 1986; Coleman el ai, 1996; Donahue,2000).

A further problem relates to the ambiguity ofmeaning in the phrase 'short-tenn memory loss'.Does it refer to type of memory or duration of loss?Robertson & Pryor (2006) recommend that thephrase 'temporary memory loss' should be usedwhen referring to duration. Patients who interpretshort-termmemory loss in tenns ofduration may notbe inclined to complain about memory difficulties,believing that they are to be expected and willresolve within the 'short term'. This may lead to anunderreporting ofmemory problems among patientswho are assessed only a few days or weeks after thecompletion ofECf andhighlighls the importance ofscheduling follow-up assessments after the 6-monthtime point (Service User Research Enterprise, 2002;Roberlson & Pryor, 2006).

Effects of mood altd emotiollal valence011 performance

Many studies have shown that individuals whoare depressed are more likely to recall negativeevents than positive or neutral ones (Teasdale et aI,1980; Parrott & Sabiny, 1990; Williams ef aI, 1988;Lemogne et aI, 2005). The performance of peoplewithout depression on tasks measuring memory andcognition may also be influenced by their currentmood. Recently, Beatty el aI's (2006) study involvinghealthy adulls showed the significance of bothcurrent mood and emotional valence (the subjectiveemotions associated with an event) on participants'ability to recall events they had experienced over thepast year. Therefore, any assessments of cognitiveand memory functioning in patients who havereceived ECfshould take account of the individual'smood at the time of testing and also whether theyperceive the event recalled as positive, negative orneutral.

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Post-ECT cogHitivc impairment

I - ,-

Box 3 Novel tasks that coiiId De used·wmea~u~e,everyday'~m~mbry'!fu~ct~oning"iri--£patientsfreceiVing.~~ , \; 1

I • -- --!- ..1 • _.Nlundane MeploryQl!esP.J2IP1~r.;," ,-:-:__,r EverydayMemoI¥.IliferVlliw!:- +,-::i·:.::~~ -.~

'Adapted Au\olliogpiphic'll·· IM~morx.. '. interview". ~,. , ': -l"! >;> - ,

,.-~ 'V.:.~. - • ,... ....:I_;•.-t'-" -':l' ••-.: '-~-:.

. • -Memory eharacreriStidThliiig Sfiile' .•, Measure~ of" mood and'metamemor,y or. m~IIlo.ry self;:gfica'cy,r =-=:",;u -.:I ':' :l:,

! • rqine-p0i:n,tglo¢d niting§ca1.e:..o ...: ~:;.: •• !~"~• _. I Fiv~-:pomt I1)-emor,y r~Hng scale: :.l: -:-. ';!:."

• TaskS. measuring topograpl¥ca~ memory, ..'. aIid'w,f Jfindth-"I51Ii'" :",. -.~ """-'"'.:' l I..:..: '---l-Yt . _g.",,!" ~.r'.~ = "-1-';"/

.•...I:'!!'drnarliRecogni~onTask "'1 • ". "'t; _ ..landmark focation Task ,_.I . .:'e -t:l

V:rr,tu'l1Mafrask·~·'F ,-;:-, .=i;'-,-.I ,. (Mangaoarig et aI, 2004)

~. I I

administered to large numbers of healthy controlindividuals of all ages and to people with chronicmajor depression (McMackin et ai, 2005). Thesetasks, which are outlined in this section, might beconsidered for use with patients following ECT.

Sellsitivittj to the nature of the patients'memory problemsEpisodic and autobiographical memory

The Mundane Memory Questionnaire specificallymeasures personally relevant episodic memory oftypical dailyevents over the previous fourconsecutivedays. Participants are asked to indicate (by circlingeither 'yes' or 'no') whether they recall a particularevent, for example, watching television or eatinglunch. If the event is recalled, they are asked to giveadditional information such as what programmesthey watched or what food they ate. If participantsare unable to provide additional details, they areasked to proceed to the next question.

This measure was extremely sensitive to the typesof everyday memory problem experienced by thepatients in our study of temporal lobe epilepsy(Mangaoang etaI, 2004). Itdiffers from questionnairessuch as the Everyday Memory Questionnaire(Sunderland et ai, 1984), the Prospective andRetrospective Memory Questionnaire (Smith etai, 2000) and the Cognitive Failures Questionnaire(Broadbent et ai, 1982) in that it does not requirepatients to rate their own memory performance,thereby taking account of the observation that somepeople with memory problems cannot accuratelyrate the level of their impairment.

Novel tasks for measuringeveryday memoryA few years ago one of us (M. M.) was involved ina study of the effects of surgery for temporal lobeepilepsy (Mangaoang et ai, 2004). The study teamdeveloped tasks for assessing aspects of everydaymemory functioning and spatial representation inpatients after surgery (Box 3). These have since been

Memortj self-efficacy and metamemortj

According to Ponds & Hendriks (2006), patients'complaints about their memory do not necessarilyreflect memory deficits; furthermore, there may belarge discrepancies between the severity ofmemorydisturbances as measured by memory tests and theimpact of these problems in daily life. Finding onlymoderate correlations betvveenself-reported memoryproblems and objective results on standardisedneuropsychological assessments, Ponds & Hendriksintroduced the idea of memory self-efficacy (Box2) to explain this discrepancy. They argue that anindividual's beliefs and perceptions about theirmemory maybe extremely influential in determiningtheir level of engagement and performance duringmemory assessment. The belief that one has apoor memory may lead to increased dependenceon others, avoidance of memory challenges, and apattern of helplessness and demoralisation whenfaced with memory difficulties (Elliot & Lachman,1989). Additional evidence of the impact of self­perceived memory capacity on control of memoryefficiency (Cavanaugh & Poon, 1989; Hertzog et ai,1990;'jonker et ai, 1997) supports the argument thatneuropsychological assessments ofpatientswho havehad ECT should take account of the patient's ownmetarnemory or sense of memory self-efficacy.

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The Everyday Memory Interview is based onan interview used by Eldridge et al (1994) in theirassessment of the role ofschemas inautobiographicalmemory. Ina tape-recorded interview, the participantis asked to describe, in as much detail as possible,their typical day, yesterday and a day in the previousweek, in counterbalanced order (to control for ordereffects or bias) . The interview is scored by focusingon the number of basic activities that are recordedfor each of the target days. Discourse analyses of theinterview content can also be undertaken to measur~th.e frequency of repetition of events, pragmaticproblems and the use of verbal tics.

Themeritofboth the Mundane Memory Question­naire and the EverydayMemory Interview is that theymeasure the ability of patients to recall personallyrelevant events, are straightforward to administerand are free from practice effects. Modified versionsof the tasks could also be completed by patients'caregivers or spouses, should collateral informationbe desired.

Semantic and phenomenal characteristics

Although both episodic and autobiographicalmemory have been widely researched, very fewstudies have used tasks that are concise, distinguishbetween semantic and episodic information, anelcontrol for emotional valence. Semantic informationconsists of general knowledge: things we knowwithout any connection to personal experience,wfiereas episodic information refers to details suchas time, person, place and emotions about specificpersonally experienced events. Levine et ai's (2002)Autobiographical Memory Interview separates thesemantic from episodic details of events. Beattyet al (2006) adapted and extended this measure toshow how the recall of specific personally relevantevents over the previous 12 months was influencedby whether participants construed the eventsas positive, negative or neutral. The transcribedinterviews were analysed in terms of the numberof specific episodic details recalled for each type ofevent, thereby controlling for the emotional valenceof the event. This interview can be extended toinclude events from the less recent past, in orderto gain a thorough appreciation of the extent of apatient's retrograde amnesia.

Beatty et al (2006) also used the MemoryCharacteristic Rating Scale (adapted from Johnsonet ai, 1988) in conjunction with Levine et aI's (2002)Autobiographical Memory Interview to measure thephenomenal characteristics of the different events.The Memory Characteristic RatingScale uses aseven­point Likert scale to rate the vividness with whichparticipants can recall specific aspects of an event,such as visual and auditory details. This combination

of tasks facilitates examination of the associationbetween the emotional valence of an event and thevividness with which different characteristics canbe recalled.

Topographical memory

The effects of ECT on topographical memory,way-finding and spatial representation are largelyunknown. We can find only one self-report ofsuch deficits (Anonymous, 1965). Assessments ofpatients who have received ECT do not appearto consider the possibility of such impairments,despite their impact on everyday life. In our workon temporal lobe epilepsy (Mangaoang et ai, 2004;Roche et ai, 2005), we developed a number of tasks(the Landmark Location, Landmark Recognitionand Virtual Map tasks) to measure the ability ofpatients with left or right unilateral hippocampaldamage to recognise photographs of well-knownDublin landmarks and to accurately name theirlocation on a modified map of the city. Patients alsodescribed in writing the routes they would take toget from one landmark to another on a map of avirtual city. These tasks were extremely sensitiveto the everyday way-finding problems experiencedby many of the patients, particularly those withright-sided hippocampal damage (Mangaoang etai, 2004) and could potentially be used to identifywhether patients treated with ECT experiencesirnllardifficulties.

Sellsitivittj to metamel1lOnj alld 1/lood

In considering metamemory and memory self­efficacy (Box 2), the study team used a simplememory rating scale, asking patients to rate theirown perception of their current memory functioningat the time of assessment on a five-point Likert scale(1 ='very bad', 5 ='excellent').

Patients' self-reported symptoms of depressioncan be assessed using the Beck Depression Inventory(Becket ai, 1996).Altematively, McMackin et al (2005)have used a mood rating scale that asks patients torate their mood state at the time of assessment on anine-point Likert scale (1 ='worst you've ever felt',9 = 'best you've ever felt'). Either instrument couldbe easily incorporated into an assessment batteryfor patients receiving ECT.

Potential role of memory rehabili­tation and cognitive retraining

Although reports haveclaimed that about one-third ofpeople receiving ECT experience persistent memoryloss (Service User Research Enterprise, 2002; Rose

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el ai, 2003; Scott, 2005), it is undear whether patientsreceive treatment or assistance from psychiatristsor other mental heaith professionals to deal withthis disability. We do know that some patients tumto sources of help outside psychiatry (e.g. self-helpgroups) for support (Johnstone, 1999). This failureto attempt to rehabilitate patients may reinforcethe negative public image of ECT specifically andpsychiatry in general.

Adopting existing techniques:brain trauma

The importance of carrying out detailed neuro­psychological assessments of patients following ECTin order to identify persistent cognitive problemswas recognised over a decade ago (Calev, 1994).Unforhmately, however, even when cases of severeand persistent memory loss are highlighted in theliterature, no study has recommended or attemptedto provide any kind of rehabilitation or follow-upcare. Documenting persistent and severe deficitsin memory and cognition is not enough; patientsneed to be helped to adjust to the major effects thatsuch disabilities may have on their everyday lives.Robertson & Pryor (2006) recommend that testsassessing neuropsychological function of brain­injured patients be used for ECT-treated patients.We would argue that the cognitive rehabilitativetechniques that are used with brain-injured patientsshould also be considered for use with patientsexperiencing memory and/or other cognitivedisability following ECT.

During the past 20 years, the course and natureof cognitive difficulties after brain injury and thekey components of rehabilitation have becomebetter understood. The significance ofpersonalback­ground, the range of emotional responses to injuryand its consequences, and the role of coping skills inlong-term adjustment are now more readily accepted(Mateer el ai, 2005).

Cognitive rehabilitatioll therapy

Cognitive rehabilitation therapy is 'a systematic,functionally oriented service of therapeutic cog­nitive activities and an understanding of theperson's behavioural deficits' (Malia el ai, 2004). Itsaim is to achieve functional changes by reinforcingor strengthening previously learned patterns ofbehaviour, or establishing new patterns of cognitiveactivity or mechanisms to compensate for impairedneurological systems (Bergquist & Malec, 1997).Cognitive rehabilitation therapy has a large evidencebase and has been widely researched amongpatientswith acquired brain injury.

Post-ECT cognitive impairment

Memol'1j rehabilitation

Recently, Ponds & Hendriks (2006) have describedwhat appears to be the first formal attempt to offera rehabilitation programme focusing on memory topatients with epilepsy. However, no attempts haveyet been made to extend such treatment to patientswho experience memory deficits following ECT.

What rehabilitation could achieve

Designing a rehabilitation programme for patientswith memory or other cognitive disability associatedwith ECT would constitute the first step towardstreating these deficits rather than merely reportingthem. Such a programme would also acknowledgethe individual's difficulties and the challenges theyface in coping with the demands of everyday life.

How it could be done

Baseline and post-treatment neuropsychologicalassessments could be used to clarify the nature andextent of cognitive difficulties. From there, approw

priate steps towards memory rehabilitation andcognitive retraining (seebelow) could be undertakenin individual and/or group sessions, and couldbe extended to indude the individual's family orcaregivers. Follow-up assessments ofprogress wouldallow any changes in cognitive status tobe measuredand also to monitor the transfer of acquired skillsto other areas of functioning such as the social andoccupational domains of the individual's life. In thisway it would be possible to determine whether therehabilitation programme was having a beneficialeffect on the patients' overall quality of life.

Ultimately, successful practical attempts to addressthe impact of cognitive disabilities on the lives of pa­tients treated with ECTwould be welcomed not onlyby the patients themselves but also by their relativesand caregivers. The provision ofsuch a service mightalso improve potential patients' attitudes towardsECT, by reassuring them that, should they developa persistent cognitive problem following treatment,some form of structured treatment and assistancewould be made available to them. This might helpthe decision-making process for patients who areconsidering ECT as a treatment option.

Design of a successfulrehabilitation programme

There are many factors to consider in the design of acognitive rehabilitation programme. These includeunderstanding that rehabilitation is a collaborative

".

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process, recognising the importance of includingfamily and/or caregivers and being sensitive tothe impact that a patient's level of awareness, met,!-­memory, mood and motivation can have on theirability to take part in a programme. Premorbidpersonality and psychological functioning arealso extremely important. Therefore, cognitive re­habilitation should involve work on the patient'~

psychosocial skills such as coping, anxiety control,self-esteem, self-concept, motivation, locus ofcontroland adjuslment (Malia et ai, 2004).

Existing programmes

Mateerel al (2005)believe thata combination ofneuro­rehabilitation, pharmacotherapy and cognitive­behavioural therapy is often needed. Thus, manyprogrammes incorporate multiple interventionssuch as attention training, memory compensations,skills training, feedback on performance, psycho­education, stress management, confidence-buildingand psychotherapy aimed at increasing self­awareness, acceptance and adjustment.

Cognitive rehabilitation programmes that takeinto account the emotional as well as the cognitiveaspects of the injury appear to offer patients thebest chance of adapting to their altered situations(Mateer el ai, 2005). Being aware of the patient'semotional well-being is extremely important as itmay help identify the development of cognitivedistortions such as catastrophic thinking (in whichthe individual imagines the worst possible outcomeof events and situations). Catastrophic thinking canoccurwhen an individual has a distorted beliefaboutthe implications of a cognitive error or episode offorgetfulness (Mateer ef ai, 2005). For example, apatient may interpret normal lapses of memory asconfirmation ofamemory impairment thatwill neverimprove. They may have difficulty in distinguishingbetween a normal memory lapse and a cognitiveerror that commonly results from a genuine brainimpairment and this may reduce the individual'sability to cope. Cognitive appraisal and beliefs ofself-efficacy are increasingly recognised as beingcrucial to an individual's ability to manage stress(Lachman el ai, 1992; Mateer ef ai, 2005).

Recommendations for successfulrehabilitation

Approaches to successful cognitive rehabilitationconsider both general and specific aspects of thepatient's difficulties (Box 4). The general aspectsfocus on psychoeducation covering the effects ofbrain damage and cognitive difficulties, the impact

of personality changes and emotional reactions,and the perception of cognitive disorders (Malia &Brannagan, 2004; Ponds & Hendriks, 2006). Aspectsspecific to memory rehabilitation address the typesof memory problem that should be targeted fortrealment and the best strategies that could be used(Ponds & Hendriks, 2006). Trealment plans shouldbe given to the patient, caregivers or family membersand the appropriate hospital staff. Progress on thetrealmentplan should be reviewed regularly (Maliael ai, 2004).

Psyclwedltcatioll

At the earliest possible stage, patients should be fullyinformed of their cognitive problems and their likelyprognosis in terms of cognitive function (Malia et ai,2004; Mateer el ai, 2005). Education should take placeboth in formal educational groups for patients andtheir carers / families and during regular individualcontact with the patient, and it should be seen as anongoing process (Malia ef ai, 2004). Group sessionsshould focus on understanding specificbrain injuriesand what rehabilitation is all about, cognitive andemotional problems following brain injury, how tocope with the changes experienced and developinga new sense of self.

The Society for Cognitive Rehabilitation (Maliaet ai, 2004) states that the aim of psychoeducationis to help the patient develop appropriate self­awareness, self-esteeml confidence, feelings ofpersonal control and a trusting, working relationship

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with the therapist. It believes that the importance ofeducation cannotbe overemphasised: without goodawareness, much of what is subsequently offeredwill have no enduring effects on the individual'slife in the outside world.

At present, very few patients and families areinformed about the consequences of acquired cog­nitive deficits for future life or the possibilities totrain or restore memory (Ponds & Hendriks, 2006).Creating a realistic perspective about the impact andpossibilities for improvement of memory problemsis the first importantstep in every memory treatmentprogramme. Mittenberg et al (1996) showed thatgiving head-trauma patients a booklet on recoveringfrom head injury had a significant positive effecton the number, duration and severity of reportedsymptoms (headache, memory, fatigue, concentrationdifficulties, anxiety, depression and dizziness) at 6­month follow-up.

It is crucial to give patients information on ECTduring the consentprocess (Robertson & Pryor, 2006).Moreover, if the results from neuropsychologicalassessments indicate a need for intervention, patientsshould also be given psychoeducation or informationbooklets such as those given to head-injured patients,as these can be extremely beneficial in helping toalleviate the distress experienced by patients withmild brain damage. The information may also helppatients adjust to any persistent cognitive difficultiesthey experience.

Rehabilitation techniquesand strategies

The aim of rehabilitation is not restoration butcompensation (Malia et ai, 2004). This can be achievedthrough the use of internal or external rehabilitationstrategies and modifications to the environment.Strategies adapted for use with people who haveepilepsy have been shown to improve many aspectsof their lives, including attention and memory,emotional regulation and psychosocial functioning(Ponds & Hendriks, 2006). Cognitive rehabilitationshould improve the individual's ability to functionas independently as possible in the least restrictivesetting and its end result must be to improve qualityof life and real-life skills (Malia et ai, 2004).

Studies investigating memory rehabilitationhave focused on alleviating many different aspectsof memory difficulties. These include both generalmemory problems such as learning and retrieval,and specific problems with orientation, dates, names,faces, routes or appointments (Wilson et ai, 2001;Boman et ai, 2004; Avila et ai, 2004). Rose & Brooks(2003) have higWighted the potential role of virtualreality paradigms in memory rehabilitation.

post-EeT cognitive impairment

According to Ponds & Hendriks (2006), twogeneral approaches are currently used in memoryrehabilitation: drill and practice, and compensatorystrategies.

Drill and practice

The patient is encouraged to practice repeatedlyspecific memory tasks. This leads to an improvementon these tasks onlYi there is no transfer of benefitsto general memory.

Compensation

This second approach involves teaching the patientcompensatory internal and/or external strategiesfor copingbetter with everyday memory problems.Internal memory strategies comprise verbal andvisual techniques. These encourage the patient tofocus on linking isolated items, via associations, andon enriching the 'to-be-remembered' informationwith additional retrieval cues. The success of internalmemory strategies may be due to the deeper levelof processing and the elaboration of informationthat this brings about (Ponds & Hendriks, 2006).External memory strategies include devices that areused to store information (e.g. a calendar, diary; voicerecorder or portable electronic organiser) or remindpeople to perform a particular activity ata specifiedtime (Wilson et ai, 2001; Hart et ai, 2004; Kapur et ai,2004; Kirsh et ai, 2004).

External strategies also include rearranging ormakingmodifications to theindividual's environment,for example always keeping important items such askeys, wallet or purse and diary together in a labelleddrawer in the kitchen (Ponds & Hendriks, 2006).Clearly, internal strategies require greater cognitivecapacity and insight than extemalstrategies becausethe strategy has to be remembered at the very timethe individual is becoming overwhelmed with thedemands of a task (Maila & Brannagan, 2004).

Process training

Strategy teaching is an integral part ofwhat is knownas 'process training' in cognitive rehabilitation (Maliaet ai, 2004). Process training attempts to stimulatepoorly functioning neurological pathways in thebrain in order to maximise their efficiency and effec­tiveness. It aims to overcome damage by using bothnew, undamaged pathways and old partially dam­aged ones. Process training involves comprehensiveassessment and an analysis of the results of this usinga practical cognitive model. Regular reassessmentshould be undertaken to ensure that the patient ismoving towards the agreed functional goals, and theresults should determine the direction and progressthrough the process-training exercises.

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Maugaoallg & Lucey

Evidence shows that the use of process-trainingmaterials designed on thebasis ofneuropsychologicaltheories and arranged into a structured programmecan lead to gains in the majority of patients (Bomanet al,2004). Studies have aisohighlighted the benefitsofusing computerised assessment and rehabilitatio~tools in memory process training (Moore et aI, 200LTam &Man, 2004; Cappa et aI, 2005).

Why is post-ECT rehabilitationso uncommon?

There are many reasons why no one has yet triedto introduce cognitive rehabilitation for patientswho report persistent cognitive difficulties afterECT. Until recently, there appears to have been ageneral reluctance among psychiatrists to admitthat ECT could cause memory or other cognitiv~

problems that are severe, persistent and disabling.Even when patients show significant impairmentsin memory functioning, there has been considerabiedebate regarding the extent to which these maybe attributable to ECT as opposed to factors suchas depression (Robertson & Pryor, 2006). Ther~has also been a failure to acknowledge the effectthese consequences on the patient's sense of sell(Johnstone, 1999).

-The deiay in implementing in routine clinicalpractice the guidelines and recommendations forthe neuropsychological assessment of patients at.any stage during programmes of ECT has been asignificant contributory factor. Furthennore, wh~patients receiving ECThave been assessed, the focushas generally been on documenting deficits ratherthan suggesting how to treat them. 11 is possiblethat psychiatrists have limited knowledge about thetypes of cognitive problem experienced by patients,how they affect their lives and what could be doneto facilitate the recovery of cognitive functions orcompensate for persistent deficits. They may also beunaware of the potential role of rehabilitation, whatit involves and how it may infonn the treatment andmanagement of patients under their care.

However, the main reason for the near absenceof post-ECT rehabilitation may be the lack ofspecialist neuropsychological services available toECT psychiatrists and treatment teams (Robertson&'Pryor, 2006). A psychiatrist may well recognisethe merit of rehabilitation programmes but haveno one to whom the patient can be referred. InIreland, neuropsychology services are severelyunderdeveloped, particularly outside of Dublin.Therefore, the lack of suitably qualified personnelwith expertise in this area is a significant problem.Multidisciplinary team approaches that includepsychiatrists, neuropsychologists, occupational

therapists, social workers and community liaisonofficers may be an integral part of best practicerecommendations in cognitive rehabilitation, butin reality such services may not be available.

Conclusions

All patients should undergo cognitive assessmentbefore their first ECT session. Subsequent compre­hensive neuropsychological assessments shouldbe routin:~yun.der~~ken if patients report memoryand cogrutive dlSability follOWing ECT. Assessmentsshould take into account baseline (pre-treatment)functiorung and should use tasks that are sensitiveto the nature of the patient's everyday problemsand that take account of the influence of patient'scurrent memory, sense of memory self-efficacy andmood. Reassessment should be scheduled after asufficiently long interval (more than 6 months aftertre~~ent)so ~atp.ersistent cognitive and memorydefICIts can beldenti..fied. Furthermore, patients' self­reports of adverse side-effects, particularly thoseconcerning deterioration in memory and cognitionwhileundergoing acourse ofECT, should be properlyinvestigated by staff in the ECT clinic (NICE, 2003;Benbow & Crentsil, 2004).

It should now be clear that documenting neuro­psychological deficits is not enough; a specificprogramme of cognitive rehabilitation should bedesigned and made available to all patients withpersistent cognitive difficulties following ECT, anddetaiis about this treatment should be includedwith the infonnation that patients receive priorto treatment. This programme should incorporatemethods of training and strategy learning of knownefficacy that aim to generalise skills to all domainsof the patient's life. Clinicians should be awarecognitive rehabilitation appears to be rnost successfulwhen patient's physical, psychological, social andvocational well-being are considered together andwhen the programme is extended to include thefamily or caregivers (Mateer et ai, 2005).

Cognitive rehabilitation following ECT offers aconstructive way of treating and managing the mostcommonly reported side-effect, which is currentlyleft untreated. Over time, this acknowledgement ofthe presence and impact of cognitive disability inECT-treated patients, together with the educationofpatients, families and mental health professionaisabout ways to deal with these difficulties, wouldlead to better overall adjustment by patients andthe development of a new sense of self.

Declaration of interest

None.

98 Advances ill Psychiatric Treatment (2007), vol. 13. http:! / apt.rcpsych.org/

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MCQs1 Patients currently referred for ECT complete routine

neuropsychological assessments:a following the couese of Eef treatmentsb prior to receiving the first Eef treatmentc 3 months after the last Eef treatmentd 6 months after the last Eef treatmente patients do not routinely complete newopsychologica1

assessments at any stage dwing treatment.

2 The following are not necessary in neuropsychologicalassessment of patients receiving EeT:

a the Eysenck Personality Inventoryb recommendations for treatment or rehabilitation of

impairmentsc tasks measuring 'real-world' functioningd collateral information from the patient's family or

caregiverse measwementoffactorsinfluencingapal::ient's'cognil::ive

reserve'.

3 Tasks that require patients to self·ra.te their ownmemory functioning include:

a the Landmark Recogni tion Taskb the Mundane Memory Questionnairec the Autobiographical Memory Interviewd the Prospective and Retrospective Questionnairee the Everyday Memory Interview.

4 Cognitive rehabilitation is least successful when itfocuses on:

a compensation for deficit rather than restoration offunction

b the cognitive and emotional aspects of brain injuryc including the patient's family or caregivers in the

rehabilitation processd the drill and practice approache the generalisation of acquired skills to the social and

vocational domains of the patient's life.

S Cognitive rehabilitation techniques have beenadapted and used for:

a patients with acquired brain injuryb patients with permanent memory and cOgnitive

disability follOWing ECTc patients with inleliectuaJ (learning) disabilityd patients with temporary memory and cognitive

problems following ECfe all of the above.

-MCQanswers

1 2 3 4 5a F aT a F a F a .Tb F b F b F b F

.-b .F ..

c F c F c F c F c F~

d F dF g·T ·d· T dFe T e F e F .. F e F

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