Pmg. Neum-Psychopharmacol. 6 Biol. Psych% 1989, Vol. 13, pp. 693-700 027a5846/89 $0.00 + .

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Printed in Great Britain. All rights reserved 0 1989 Mwvell Pergamon Macmillan plc

REDUCTION OF POST-ECT MEMORY COMPLAINTS THROUGH

BRIEF, PARTIAL RESTRICTED ENVIRONMENTAL
STIMULATION (REST)

PETER SUEDFELD, CARMEN E. RAMIREZ, RONALD A. REMICK AND

JONATHAN A.E. FLEMING

Departments of Psychology and Psychiatry

The University of British Columbia and Shaughnessy Hospital
Vancouver, British Columbia, Canada

(Final form, September 1988)

Peter Suedfeld. Carmen E. Ramirez, Ronald A. Remick and Jonathan A.E. Fleming;
Reduction of Post-ECT Memory Complaints through Brief, Partial
Restricted Environmental Stimulation (REST). Prog. Neuro-Psychopharmacol.
Biol. Psychiat. 1989. J&693:700

1. A previous paper (Suedfeld, et al. 1987) reported on preliminary results

of placing patients into a room with substantially reduced environmental
stimulation (REST) Immediately after recovery from ECT.

2. Comparing two depressed patients who had undergone this experience with
three who had instead returned to their own hospital room (Ward), Suedfeld
et al. (1987) found that the former registered much fewer complaints
concerning memory loss related to ECT administration than the latter.

3. The current report extends this finding to a total of 19 patients, of whom

13 completed four testing sessions. Once again, objective tests of memory
showed no significant change as a function of ECT. Both groups of
patients complained of substantial memory disruption after the first ECT.
By the one-week followup, such complaints were minimal among REST patients
but showed only a slight decline among the Ward group. This was the only
significant intergroup difference.

Kevwords: amnesia, ECT, memory, restricted environmental stimulation, REST.

electroconvulsive treatment (ECT), restricted (or reduced)

stimulation therapy (or technique) (REST).

lntroducti PO

A previous paper (Suedfeld et al. 1987) reviewed evidence concerning memory

loss after ECT. In general, it has been found that parameters of the ECT

procedure and the specific tests used significantly affect the results. In

the former area, such characteristics as waveform. power* and electrode

placement play important roles; in the latter, effects differ among retrograde

and anterograde, verbal or nonverbal, short- or I ong-term, and objective

versus subjective tests of memory impairment. Test administration variables

are also relevant. However, one general conclusion seems quite consistent:

persistent memory deficits figure much more reliably in the subjective

self-reports of patients than on any objective test applied so far (Squire 8

693
694 P. Suedfeld et al.

Chace, 1975). This finding is quite relevant to the often-emphasized view

that ECT is a technique to be avoided and abandoned whenever possible, In

spite of its thoroughly demonstrated effectiveness In the treatment of

affective disorder.

The earlier report also laid the foundation for the use of restricted

environmental stimulation (REST) in an attempt to alleviate post-ECT memory

disturbance. REST research with normal subjects had shown that in many cases

the experience leads to improved recall (Suedfeld, 1969); with infrahuman

organisms, REST imposed immediately after electroconvulsive shock resulted in

significantly less retrograde amnesia than a return to a more stimulating

environment such as the home cage (Calhoun et al. 1975; Hinderliter et al.

1976; Peters et al. 1973).

Based on these observations. we initiated a study in which depressed

patients who had been prescribed ECT in the course of treatment were offered

the option of being placed in a room with reduced stimulation for a few hours

after recovering from each experience of ECT (and anaesthesia). Various tests

of memory were administered one or two days before the first ECT session,

Immediately after that session, immediately after the last ECT, and one week

after the ECT series was completed. The Suedfeld et al. (1987) paper

represented early results, with only two patients in the REST group and three

in a Ward group that returned to regular hc.spltal rooms after recovery from

ECT. The only notable findings were that there was a decline on most tests

from the pre-ECT baseline to the administration immediately following the

first electrical treatment, but these disruptions had essentially disappeared

by the one-week followup. The exception was on self-reported memory loss,

which persisted among Ward but not among REST patients.

The current paper reports the extension of these procedures to a total of 19

patients.

Over a period of three years, 35 patients were screened as potential

participants. Nineteen (Table 1) volunteered and took part in at least the

first two testing sessions. The remaining patients were eliminated from the

study because they did not wish to continue participating in the memory
 Reduction of post-ECT memory complaints 695

tati ng; did not wish to continue participating in REST; had medical

camp I ications after the first ECT session; or were re-diagnosed as suffering

from other than major depression.

Table 1

Demographic and Background Characteristics.

Age Sex Marital Previous ECT Trtmt. Gp. No. of ECTs

#_(~~~~___M_.~___.S___.M._..D__~_.__~~~____NO_..__.RESJ..._~~~--__M~~L~~~~Z_
47.4 9 10 14 2 3 10 9 10 9 11 (7 - 15)

Of the remaining 19 patients , only 13 completed al I four testing sessions.

Most of this loss was due to the unwillingness of the patient to be tested

after a par-titular ECT experience. There were other variations i II :~hl;~pIc: size

caused by patients refusi ng to take a particular test with i n the battery. cvc.r:

though they wished to continue in the study. Additional sample loss also

occurred because some patients who lived out of town were unable to keep the

followup psychiatric appointment. At least 16 patients completed each test

during the course of ECT, and 13 on followup.

lnLLusncI~

As in the earlier portion of the study (Suedfeld et al. 198718 the nclusion

criteria were:

1. Diagnosis as major depressive episode according to DSM-III triter a;

2. Competence to understand and voluntari ly sign the consent form, with

legally certified (i.e., Involuntary) patients being automatically

eliminated;

3. Competence to respond to orientation interviews and memory tests;

4. No ECT administrations within the previous :.ix fiIor:ths (this was a change

from the previous 12-month limit, which eliminated too many otherwise

qualified patients).

All patients who met these criteria and who were scheduled for ECT at

Shaughnessy Hospital or the UBC Health Sciences Centre Psychialric Hospital

696 P. Suedfeld et ai.

were interviewed by a member of the research team. Because of the nature of

the subject population, and in view of apprehensions on the part of nursing

staff and others, particular care was taken to explain the procedures in great

detail and to offer particlpatlon in a maximally open-ended, nonthreatening

way.

Ail eligible patients who agreed to participate were randomly assigned to

either the REST or the Ward group. ECT was administered as sinusoidal current

(Modcraft machine) to the right hemisphere, for 0.5 to 1.0 sec. at 110-170

volts. Standard anaesthesia Gnethohexitai, succinylchoiine) was administered

prior to ECT. Treatments were given every third day when possible, and most

patients received 8-12 treatments In the series with a mean of 11.

After each time that the patient had undergone ECT and then recovered from

the anaesthetic in the usual recovery room. REST patients were taken to a

small room from which ail furniture excepi the bed had been removed. The room

was dimly iIluminatedr and was located so that ambient nolse was quite low.

This partial-REST condition (as opposed to the complete darkness and

soundproofing typically used in experimental studies) was felt to be less

anxiety-arousing for patients. An intercom was installed, and a monitor just

outside the room kept constant watch over the patient. Requests for something

to drink, to go to the toilet, etc., were responded to by the monitor, as were

any requests to come out of the room. Nurses were allowed into the room to

monitor blood pressure or dispense medication when necessary.

Patients were asked to remain in the r- for a mlnimum of two hours and

were permitted to remain for a maximum of four hours. All of the REST group

patients included in the statistical analysis completed at least two hours In

the environment after each ECT administration.

In accordance with standard procedures. patients In the Ward condition were

sent back to their own room in the hospital after recovery from anaesthesia.

Typically, they would sleep between 30 and 90 min. and then have breakfast and

engage in ward activities. No active procedures were initiated to control

embient noise or room iiluminat~on for patients in the Ward condition.

The tests (mostly taken from batteries developed for use with clinical

patients: Moyral 1968; Squire et ai. 1979) measured word iearning and recailr
 Reduction of post-EC3 memory complaints 697

memory for figures, spatlal recall I dlgit span retentionr memory for

significant events in the patientqs own life , and an assessment of self-rated

improvements and Impairments in memory compared to the pre-hospitalization

period. Equivalent test forms were used when available. The goal was to

cover both long- and short-term memory, objective and self-evaluation formats,

and verbal as well as nonverbal materials.

Testing was conducted on the following schedule:

1. I&sQL~B: One or two days before the patient was scheduled to receive the

first ECT of the series;

2. Post Firslt_a: All ECT treatments being administered in the morning, the

memory tests were given dui ing <he e\srIng of the day when the first ECT

had been applied;

3. PosttasJ-=ECI: The evening of the day when the last ECT of the series had

occurred. This varied. depending upon the number of ECTs prescribed for

the particular patient;

4. Eellnrvup.: One week after the ECT series was compteted, on a day when the

patient was scheduled for a psychiatric appointment. The tests were given

either immediately before or immediately after this appointment, depending

upon the patients and psychiatrists preference and convenience.

&tatistical &&ys_is

Because of the small and variable ns, test scores were analyzed using the

Median Test and Fishers Exact Probability Test. Correlation coefficients

were calculated among scores on the different memory tests.

The results of the preliminary report were esser:liai!y replicated. There

was no consistent memory loss on the objective tests of performance as a

function of ECT (Table 2). Any deficits that did occur had largely been

remedied by the time of followup. There were no significant correlational

patterns among tests (e.g., within or across such categories as

verbal/nonverbal, long-term/short-tarm memory), variance was highs and

previous ECT experience was not reliably related to test scores.

When one compares the two treatment conditions across the repeated

administrations, the very temporary nature of deficits in objective memory

698 P. Suedfeid et al.

scores becomes obvious. There were essentially no decrements from the

baseline to the post-first ECT tests9 and most followup sccrf::. tore (ii ieast

as good as their counterpart at baseline. Subjective memory complaints showed

a dramatic decrease from the test administered immediately after the first ECT

to followup among REST patients (M = 18.9 to 3.6). Among Ward patients,

complaints were still at a fairly high level at followup (M = 13.21, although

not as high as after first ECT (18.1). There were significantly fewer

complaints on followup among the REST than among the Ward group (Fisher Exact

Probability Test p = .025). There were no other statistically significant

results.

Table 2

Mean (Median) Test Scores

Test and Group Baseline Post 1st ECT Post-Last ETC Followup

Life Events (Errors)

REST 6.9(5) 7.0(8) 7.1(5) 4.8(3)

Ward 5.3(Z) 6.3(3) 6.4(5) 6.1(4)

Self-Rated Memory (Complaints)

REST 8.6(6) 18.9(11) 2.4(3) 3.6(O)

Ward 7.6(14) 18.1(12) 14.5(15) 3.2(4)

Digit Span (Correct)

REST 10.7(11) 11.3(11) ll.l(ll) 11.0(9)

Ward lO.l(lO) 11.2(11) 10.8(9) 10.7(9)

Spatial Memory (Errors)

REST 6.4(6) 5.0(5) 3.6(2) 4.1(O)

Ward 3.6(l) 3.2(3) 2.7(2) 2.3(l)

Figure Recall (Errors)

REST 5.4(6) 4.0(4) 9.4(3) 6.1(2)

Ward 6.1(4) 3.6(2) 3.0(2) 3.1(2)

Word Learning (Errors)

REST 21.0(29) 16.8(21) 19.5(16) 21.8(15)

Ward 18.0(16) 11.3(6) 16.3(11) 14.2(15)

 Reduction of post-ECT memory complaints 699

Memory loss after ECT is a relatively complex and evanescent phenomenon.

Objective testing of a wide range of memory functions has failed to support

claims of substantial or long-lasting amnesia. However, introspective reports

of patients who have undergone ECT indicate a feeling that memory disturbances

have occurred. Our most striking finding was the dramatic increase in memory

complaints among the REST group from a very low baseline to after the first

ECT (equaling the level of the Ward patients), and the even more dramatic

decline from then to followup. The Ward subjects had much higher baseline

scores, which decreased slightly throughout the course of ECT and on followup.

Since adverse self-reports form an important basis for attacks on the use of

ECTI and in view of the efficacy of ECT as a treatment for major depressive

episodes, it would obviously be beneficial to reduce or eliminate the causes

of such complaints.

It appears that brief, partial REST may serve this function. As the

technique is also easy to adminlster (and to terminate If the patient so

wishes), cheap, and safe, its use should be considered in designing post-ECT

recovery procedures. Further research (e.g., on the optimal number, duration

and timing of REST sessions and comparison of EF,PT with a credible placebo

iechnique) is desjrable to establish the place of this method in protecting

ECT patlents from feeling that they have suffered memory loss.

Complaints of Gary deficits declined dramatically from the first session in

an ECT series to a followup one week after the end of the series among

patients whose post-treatment recovery took place in a stimulus-reduced

environment (quiet, dimly lit, limited movement and social interaction for 2 -

4 hours). This procedure, which is economical and had no negative

side-effects, may be usefully incorporated in standard protocols.

This research was made possible by funding from the British Columbia Health

Care Research Foundation. We are grateful for i-he cooperat ion of the staff

and patients of Shaughnessy Hospital and the University of British Columbia

Health Sciences Centre Hospitals , and for- the collaboration of Susan Bluckt

Rodney Day, Alistair Wallbaum, G.K.Y. Wang, and Shauna Woolley. A report of

this research was made at the Third international Conference on REST, New York

City, Aug. 1987.

700 P. Suedfeld et al.

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MOYRA, W. (1968). The measurement of memory in clinical practice. Brit. J.

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SQUIRE, L.R. 8 CHACE, P.M. (1975). Memory functions six to nine months
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SQUIRE, L.R., WETZEL, C.D., 8 SLATER, P.C. (1979). Memory complaint after
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SIJEDFELD, P. (1969). Changes in intel lectual performance and in

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Inquiries and reprint requests should be addressed to:

Dr. Peter Suedfeld

Department of Psychology
The University of British Columbia
Vancouver, B.C., Canada V6T lW5