In patients with schizophrenia or schizoaffective disorder who are scheduled to undergo electroconvulsive therapy (ECT), the presence of anxiety symptoms at baseline is associated with reduced ECT efficacy, as shown in a study.
In a retrospective cohort of 979 patients with schizophrenia or schizoaffective disorder who received ECT at a tertiary public psychiatric hospital in Singapore, pre-ECT anxiety was associated with poorer treatment efficacy, as measured using the Clinical Global Impression-Improvement (CGI-I) scale (adjusted β, –0.11; p=0.03). [J ECT 2026;doi:10.1097/YCT.0000000000001315]
Pre-ECT anxiety was assessed using the Brief Psychiatric Rating Scale (BPRS), with scores exceeding 6 indicating the presence of anxiety. A total of 515 (52.6 percent) patients had pre-ECT BPRS-anxiety subscale score of >6.
Compared with patients who had no pre-ECT anxiety, those who did have pre-ECT anxiety tended to be younger (mean age 42.48 vs 45.5 years; p=0.002) and were more likely to be receiving concurrent antidepressant therapy (28.2 percent vs 22.6 percent; p=0.05) and to have undergone ECT previously (88.9 percent vs 80.4 percent; p=0.002). No differences in gender, admission status, duration of current episodes, number of previous episodes, use of psychotropics medications other than antidepressants, or the number of previously failed psychotropic medications were observed.
Approximately 10 percent of patients provided their own informed consent for ECT, whereas around 90 percent lacked the capacity to provide informed consent and received ECT that was prescribed in their best interests.
Greater severity of pre-ECT anxiety symptoms significantly correlated with more severe baseline psychotic symptoms (r=0.13, p<0.001), negative symptoms (r=0.15, p<0.001), and manic symptoms (r=0.41, p<0.001).
Additionally, the presence of more severe pre-ECT anxiety symptoms correlated with poorer quality of life measured using the EuroQol-5 Dimension Visual Analogue Scale (r=−0.30, p<0.001) and lower global functioning assessed using the Global Assessment Function scale (r=−0.18, p<0.001). No significant association was observed between pre-ECT anxiety symptoms and baseline cognitive function, as measured using the Montreal Cognitive Assessment tool.
These associations suggest that anxiety may compound the overall illness burden in schizophrenia, contributing to emotional distress, reduced coping capacity, and increased functional impairment, according to the authors.
As for why patients with anxiety, including those with more severe anxiety, had poorer ECT outcomes, the authors pointed to the possibility of anxiety functioning as an independent negative prognostic marker.
“Potential mechanisms include interference with treatment engagement, medication-related modulation of seizure quality, and broader affective or stress-sensitive illness subtypes that are less responsive to ECT. These findings underscore the importance of recognizing anxiety not merely as a secondary symptom but as a clinically meaningful modifier of ECT response,” they noted.
As such, it is important that clinicians assess anxiety symptoms before administering ECT, the authors said.
“Future prospective studies using validated anxiety-specific instruments are needed to further examine and confirm the association between pre-ECT anxiety symptoms and ECT treatment outcomes,” they added.