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Ask the Mental Health Expert Archives 2001-2004

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Memory Problems

Q. A psychiatrist colleague and I have worked with three patients who suffer from significant depression. They each have histories of severe childhood sexual abuse and varying levels of dissociation. All three have been highly suicidal.

After much therapy, trials of medication and hospitalization all three patients have been given electroconvulsive therapy (ECT) treatments for the depression. Though the ECT seems to help the depression temporarily, all three patients have experienced severe memory problems beyond what is usual--such as forgetting the birth of a baby a year earlier, forgetting therapy sessions where there had been some gain, not recognizing people they know well or what their house looks like and other life situations spanning a long length of time.

Is there anything written or do you have ideas about these kinds of situations? We fear the effects of therapy are lessened yet do recognize that there is some relief from the depression. The memory problems are severe and have caused these patients extreme frustration and at times fear, feelings of disorientation and humiliation.

A. The memory problems you describe for these patients would be extremely rare and atypical as manifestations of ECT per se. That doesn't mean it's impossible, but I would bet on other factors, probably related to dissociative phenomena.

A good review of ECT's effects on memory is provided by Lisanby et al (Arch Gen Psychiatry. 2000 Jun;57(6):581-90.). They examined the short- and long-term effects of differing forms of ECT on memory of personal and impersonal (public) events. Fifty-five patients with major depression were randomly assigned to right unilateral (RUL) or bilateral (BL) ECT, each at either low or high electrical dosage. The Personal and Impersonal Memory Test was administered by blinded raters at baseline, during the week after ECT, and at the 2-month follow-up. Normal controls were tested at matched intervals. It was found that, shortly after ECT, patients recalled fewer events and event details than controls, with the deficits most marked for impersonal compared with personal events. Bilateral ECT caused more marked amnesia for events and details than RUL ECT, and especially for impersonal memories. These effects were independent of electrical dosage and clinical outcome.

At the 2-month follow-up, patients had reduced retrograde amnesia, but continued to show deficits in recalling the occurrence of impersonal events and the details of recent impersonal events. The authors concluded that, "The amnestic effects of ECT are greatest and most persistent for knowledge about the world (impersonal memory,) compared with knowledge about the self (personal memory); for recent compared with distinctly remote events; and for less salient events." Thus, it would be extremely unlikely that ECT could induce amnesia for, say, the birth of a baby or recognizing a close friend. I would speculate that certain highly-charged, emotionally cathected experiences might be selectively repressed in patients with a history of severe abuse and dissociative features.

To test this hypothesis, it might be interesting to give these patients the DES (Dissociative Experiences Scale) along with some type of biographical memory test, and see if you find a correlation; e.g., as DES scores drop, does personal recollection increase? Another option--though one fraught with medico-legal risk--would be attempting an amytal interview, to see if the lost memories could be recovered.

However, in patients with the sort of severe abuse history you describe, I would be very reluctant to recommend this, unless you had a consultative recommendation from an expert in PTSD who had examined these patients. It might be more productive simply to help these patients "live with" their spotty memory losses, and stay out of another major depression. Down the road a ways, Transcranial Magnetic Stimulation (TMS) might be considered as an alternative to ECT for these patients. You may also want to discuss these cases with Dr. Lisanby's group, to see if they have experience with this type of problem (Department of Biological Psychiatry, New York State Psychiatric Institute, New York 10032, USA. SHL24@columbia.edu).

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January 2004

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