Changes in Symptoms and Cognition Following Electroconvulsive Therapy in Late-Life Depression: Analyses Stratified by Baseline Anxiety Levels
4 affiliations
- 1Beijing Key Laboratory of Mental Disorders, National Clinical Research Center for Mental Disorders & National Center for Mental Disorders, Beijing Anding Hospital, Capital Medical University, 100088 Beijing, China
- 2Advanced Innovation Center for Human Brain Protection, Capital Medical University, 100088 Beijing, China
- 3Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, GA 30307, USA
- 4Mental Health Service Line, Joseph Maxwell Cleland Atlanta VA Medical Center, Decatur, GA 30033, USA
Abstract
Background:: Late-life depression (LLD) is commonly complicated by comorbid anxiety. However, whether the severity of baseline anxiety is associated with differential symptomatic and cognitive outcomes following electroconvulsive therapy (ECT) in LLD remains unclear, particularly with respect to cognitive safety in high-anxiety older patients.
Methods:: This prospective self-controlled pre–post study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Ninety-three patients aged ≥60 years with LLD received an acute course of ECT and were stratified into mild-to-moderate anxiety (Hamilton Anxiety Rating Scale [HAMA] score 14–28) and severe anxiety (HAMA score ≥29) groups according to established HAMA severity cutoffs. Depressive symptoms (24-item Hamilton Depression Rating Scale [HAMD-24]), anxiety symptoms (HAMA-14), and cognitive performance (Montreal Cognitive Assessment [MoCA] and Repeatable Battery for the Assessment of Neuropsychological Status [RBANS]) were assessed at baseline and after completion of ECT treatment. Linear mixed-effects models (LMMs) with participant-level random intercepts were used to examine differential treatment trajectories while adjusting for demographic characteristics and baseline symptom severity. Hierarchical regression analyses were performed to determine whether improvement in anxiety symptoms (ΔHAMA) predicted antidepressant response (ΔHAMD) and cognitive change (ΔMoCA).
Results:: Both groups demonstrated significant reductions in depressive and anxiety symptoms following ECT. Baseline HAMA and HAMD-24 scores were not significantly correlated (r = 0.12, p = 0.24), suggesting that anxiety and depressive symptom severity represented distinct constructs. After multivariable adjustment, the severe anxiety group showed an antidepressant response comparable to that of the mild-to-moderate anxiety group (HAMD-24 total score interaction, p = 0.155), but exhibited significantly greater improvements in HAMA total and subdomain scores (all p < 0.01), as well as in the HAMD anxiety/somatization and retardation factors (both p < 0.05). Global cognitive performance remained stable across groups, with no significant differences observed in MoCA or RBANS total scores (both p > 0.60). Improvement in the RBANS attention domain was the only cognitive outcome that differed significantly between groups, favoring the severe anxiety group (p = 0.004). Greater improvement in anxiety symptoms predicted a stronger antidepressant response (β = 0.31, p < 0.001); however, this association did not differ between anxiety severity groups (p = 0.316) and was not related to cognitive change (p = 0.443).
Conclusions:: In patients with LLD, more severe baseline anxiety does not predict a greater overall antidepressant response to ECT but is associated with preferential improvement in anxiety-related and psychomotor symptom dimensions. ECT does not adversely affect global cognitive functioning regardless of baseline anxiety severity. These findings suggest that anxiety severity may help inform expectations regarding domain-specific symptomatic improvement and support the cognitive safety of ECT across the spectrum of anxiety severity in older adults.
Clinical Trial Registration:: This study is registered on the Chinese Clinical Trial Registry (ChiCTR) at https://www.chictr.org.cn/showproj.html?proj=205598 (registration number: ChiCTR2300078063).
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BibTeX
@article{zhen2026changes,
title = {{Changes in Symptoms and Cognition Following Electroconvulsive Therapy in Late-Life Depression: Analyses Stratified by Baseline Anxiety Levels}},
author = {Wenfeng Zhen and Han Wu and Shuo Lin and Dandi Zhu and Siyuan Lian and Li Ren and Yilang Tang and Yanping Ren and Xin Ma},
journal = {Alpha Psychiatry},
year = {2026},
month = sep,
doi = {10.31083/ap51154},
url = {https://doi.org/10.31083/ap51154},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Changes in Symptoms and Cognition Following Electroconvulsive Therapy in Late-Life Depression: Analyses Stratified by Baseline Anxiety Levels
AU - Wenfeng Zhen
AU - Han Wu
AU - Shuo Lin
AU - Dandi Zhu
AU - Siyuan Lian
AU - Li Ren
AU - Yilang Tang
AU - Yanping Ren
AU - Xin Ma
PY - 2026
DA - 2026/09/09
JO - Alpha Psychiatry
DO - 10.31083/ap51154
UR - https://doi.org/10.31083/ap51154
AB - Background:: Late-life depression (LLD) is commonly complicated by comorbid anxiety. However, whether the severity of baseline anxiety is associated with differential symptomatic and cognitive outcomes following electroconvulsive therapy (ECT) in LLD remains unclear, particularly with respect to cognitive safety in high-anxiety older patients. Methods:: This prospective self-controlled pre–post study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Ninety-three patients aged ≥60 years with LLD received an acute course of ECT and were stratified into mild-to-moderate anxiety (Hamilton Anxiety Rating Scale [HAMA] score 14–28) and severe anxiety (HAMA score ≥29) groups according to established HAMA severity cutoffs. Depressive symptoms (24-item Hamilton Depression Rating Scale [HAMD-24]), anxiety symptoms (HAMA-14), and cognitive performance (Montreal Cognitive Assessment [MoCA] and Repeatable Battery for the Assessment of Neuropsychological Status [RBANS]) were assessed at baseline and after completion of ECT treatment. Linear mixed-effects models (LMMs) with participant-level random intercepts were used to examine differential treatment trajectories while adjusting for demographic characteristics and baseline symptom severity. Hierarchical regression analyses were performed to determine whether improvement in anxiety symptoms (ΔHAMA) predicted antidepressant response (ΔHAMD) and cognitive change (ΔMoCA). Results:: Both groups demonstrated significant reductions in depressive and anxiety symptoms following ECT. Baseline HAMA and HAMD-24 scores were not significantly correlated (r = 0.12, p = 0.24), suggesting that anxiety and depressive symptom severity represented distinct constructs. After multivariable adjustment, the severe anxiety group showed an antidepressant response comparable to that of the mild-to-moderate anxiety group (HAMD-24 total score interaction, p = 0.155), but exhibited significantly greater improvements in HAMA total and subdomain scores (all p < 0.01), as well as in the HAMD anxiety/somatization and retardation factors (both p < 0.05). Global cognitive performance remained stable across groups, with no significant differences observed in MoCA or RBANS total scores (both p > 0.60). Improvement in the RBANS attention domain was the only cognitive outcome that differed significantly between groups, favoring the severe anxiety group (p = 0.004). Greater improvement in anxiety symptoms predicted a stronger antidepressant response (β = 0.31, p < 0.001); however, this association did not differ between anxiety severity groups (p = 0.316) and was not related to cognitive change (p = 0.443). Conclusions:: In patients with LLD, more severe baseline anxiety does not predict a greater overall antidepressant response to ECT but is associated with preferential improvement in anxiety-related and psychomotor symptom dimensions. ECT does not adversely affect global cognitive functioning regardless of baseline anxiety severity. These findings suggest that anxiety severity may help inform expectations regarding domain-specific symptomatic improvement and support the cognitive safety of ECT across the spectrum of anxiety severity in older adults. Clinical Trial Registration:: This study is registered on the Chinese Clinical Trial Registry (ChiCTR) at https://www.chictr.org.cn/showproj.html?proj=205598 (registration number: ChiCTR2300078063).
SN - 2757-8038
ER -