Testing the mind when treating the brain: a clinical audit of cognitive assessments in electroconvulsive therapy

Introduction

Electroconvulsive therapy (ECT) is a highly effective treatment for mood disorders particularly when a rapid clinical response is necessary. Cognitive side effects of ECT are notable barriers in its prescribing and acceptance. Therefore, early detection of cognitive side effects will help to inform treatment decisions and offer timely patient support. Electroconvulsive Accreditation Services (ECTAS) standards recommend regular monitoring of subjective and cognitive functions before, during and after ECT. Failure to meet these standards will result in potential threat to patient safety. Despite this, compliance to ECTAS cognitive assessment standards in real world clinical practice remains unclear.

Aims

To evaluate compliance with Electroconvulsive Therapy Accreditation Service (ECTAS) standards for cognitive assessments across ECT treatment pathway and to identify patient and system level factors contributing to non-compliance

Methods

A retrospective clinical audit was held in the ECT department of a secondary mental health service. Audit population was all the patients who underwent ECT treatment from January 2025 to January 2026. Overall, fifty patients met inclusion criteria, of which two of them had two treatment courses, thereby a total of fifty-two treatment episodes were analysed (n=52). Data was collected from electronic patient records using predefined search terms and recorded using a structured audit tool. Compliance with ECTAS standards were assessed at the following time points: pre-ECT, during ECT and at 2-month follow up. The use of both subjective cognitive assessment using item 17 of the Comprehensive Psychopathological Rating Scale (CPRS) and standardised cognitive assessment tools were evaluated. Where documented, reasons for non-compliance were gathered. Descriptive statistical analysis was done.

Results

Compliance with ECTAS cognitive assessment standards was sub-optimal across all time points. At pre-ECT, 65% of patients had a subjective test of memory using CPRS whereas only 33% had an objective cognitive assessment. During ECT, subjective assessment before every treatment was completed in 67% of cases and objective assessment after every four sessions were done in only 19% of cases. Post final ECT, objective cognitive assessment was done in 31% of cases.

The most significant gap was identified at the 2-month follow up where only 17% of cases had a subjective cognitive assessment, and only 8% had an objective assessment. Furthermore, 50% of cases had no documented follow-up. Reasons for incomplete cognitive assessment were inconsistently documented. The barriers identified were patient refusal, lack of engagement due to severity of mental illness, limited clinician awareness of guidelines and lack of structured follow-up processes.

Conclusions

The audit highlighted a substantial gap between ECTAS standards and clinical practice, particularly in the time point of post-ECT cognitive monitoring. While patient related factors also contribute to non-compliance, modifiable system-level factors such as poor documentation, lack of structured follow up and limited guidelines awareness are key targets for intervention. These are valuable to improve patient safety and quality of ECT care. Specific quality improvement initiatives such as improved documentation systems, structured follow up pathways, and clinician education are being implemented in the service. A re-audit is planned in 6 months to evaluate impact.

References

1. Royal College of Psychiatrists ECT Accreditation Service (ECTAS) Quality Standards for ECT Clinics : Sixteenth Edition (August 2023)