ECCA's Turkish Validity and Reliability Study and Comparison With Other Cognitive Assessment Tests

Electroconvulsive therapy (ECT) is considered one of the first biological treatment methods used in psychiatry and is based on the induction of generalized seizures in the brain through the application of controlled external electrical current.(1)

The first use of electroconvulsive therapy (ECT) as a psychiatric treatment method was carried out in 1938 by the Italian physician Ugo Cerletti.(2) The application of electrical current to induce convulsions by Cerletti and his assistant Lucio Bini marked an important turning point in the field of psychiatry.(3)

In 1974, a task force of the American Psychiatric Association reported that ECT was beneficial in the treatment of depression, mania, and treatment-resistant schizophrenia. Since 1938, it has been applied as one of the most effective treatment options in the management of mental illnesses.(1)

Electroconvulsive therapy (ECT) is used as an effective and safe intervention in the treatment of various psychiatric disorders, particularly severe major depression, as well as catatonia, schizophrenia, and mania.(4,5)

Various theoretical explanations have been proposed regarding the mechanism of action of electroconvulsive therapy (ECT).(6) In this context, it has been suggested that ECT increases the sensitivity of brain receptors, accelerates serotonin and dopamine metabolism, activates monoaminergic systems, regulates circadian rhythm, and provides synchronization between the two brain hemispheres.(6) In addition to its antidepressant, antipsychotic, anticonvulsant, and anticatatonic effects, ECT has also been shown to have significant effects on neurotransmitter levels, neuroendocrine responses, and neurogenesis processes.(6) However, the neurobiological mechanisms through which ECT exerts its therapeutic effects have not yet been fully clarified.(6)

Among the cognitive side effects that may occur during the subacute period of electroconvulsive therapy (ECT) are anterograde amnesia, which affects the learning of new information, and retrograde amnesia, which causes difficulty in recalling previously acquired information. It has been reported that anterograde amnesia generally resolves within two months after the completion of ECT treatment. However, there is evidence suggesting that retrograde amnesia may be permanent in some cases. These cognitive effects may not be immediately noticeable during ECT sessions and may persist after the treatment. Therefore, it is recommended that cognitive functions be carefully evaluated before, during, and after ECT administration.(5)

In clinical practice, the Montreal Cognitive Assessment (MoCA) and the Mini-Mental State Examination (MMSE) are frequently used to evaluate the cognitive side effects of electroconvulsive therapy (ECT).(5,7) These scales have been shown to be effective screening tools, particularly in the early diagnosis of mild cognitive impairment and Alzheimer's disease.(5,7) However, MoCA and MMSE were not specifically developed to evaluate ECT-related cognitive effects such as retrograde memory loss, autobiographical memory impairment, and subjective memory complaints.(5,7) Therefore, it is considered that existing cognitive assessment tools may be insufficiently sensitive in detecting cognitive side effects specific to ECT, and there is a need for a new cognitive assessment instrument specifically designed for ECT with higher sensitivity.(5,7)

The Electroconvulsive Cognitive Assessment (ECCA) Test, developed to evaluate ECT-related cognitive side effects, is a structured assessment tool consisting of 30 items and was designed in Atlanta.(8) The test aims to evaluate five main cognitive domains: subjective memory, informant-rated memory, attention, autobiographical memory, and delayed verbal recall. The ECCA was developed by Dr. Adriana P. Hermida and her colleagues from the Department of Psychiatry and Behavioral Sciences at Emory University.(8)

In a study conducted in the United Kingdom in 2020, the Electroconvulsive Cognitive Assessment (ECCA) Test and the Montreal Cognitive Assessment (MoCA) were compared in a sample of 131 participants.(8) The findings indicated that ECCA may have higher sensitivity than MoCA in evaluating cognitive functions in individuals undergoing ECT. Considering the difficulties encountered in monitoring and assessing cognitive side effects caused by ECT, ECCA is considered to have the potential to fill an important clinical gap due to its rapid applicability, ECT-specific structure, and multidimensional evaluation capacity.(8)

The fact that ECCA particularly focuses on autobiographical memory and subjective cognitive difficulties makes it more than a classical neuropsychological assessment tool and allows it to reflect early cognitive effects of ECT in a more comprehensive and holistic manner. Previous studies have also shown that memory impairments occurring during and after the ECT process have significant effects on individuals' overall cognitive functioning.(8)

In a study conducted in China, ECCA initially demonstrated greater sensitivity than MMSE or MoCA in evaluating changes in general cognitive levels in patients with major depressive disorder after ECT.(7)

In conclusion, the limitations of existing assessment tools used to monitor cognitive functions during the ECT process make it necessary to develop assessment instruments specific to ECT. In this context, ECCA stands out as a functional and valuable reference tool both in clinical decision-making processes and in cognitive monitoring after treatment.(8)

Scales are measurement tools that define the rules and constraints required to classify, rank, or determine the quantity and degree of the characteristics to be measured.(9)

Scale adaptation provides time savings compared to developing a new scale and enables the use of common data collection tools across different cultures. This allows for more generalizable data and facilitates research on similarities and differences between societies.(10)

The validity and reliability of Turkish versions of tests are critical for ensuring their scientific accuracy and consistency.(11) Validity refers to the degree to which a test accurately measures the characteristic it is intended to measure, whereas reliability indicates the consistency and stability of the test.(12) High reliability shows that the test produces consistent results, while validity determines whether the test actually measures what it is intended to measure.(13) The relationship between these two concepts indicates that a valid test must also be reliable, although a reliable test may not always be valid.(14) For example, high reliability does not necessarily mean that a test is valid; the appropriateness of the test for its intended purpose must also be evaluated.(15) In this context, validity and reliability analyses of Turkish tests are important for determining their psychometric properties and ensuring their effective use in educational processes.(11)

In order to conduct the validity and reliability study of the ECCA test in Türkiye, the developer of the test, Adriana Hermida, was contacted via e-mail. During the translation process, the ECCA test was translated from English into Turkish by five individuals independently of each other; subsequently, the Turkish version was back-translated into English by five different individuals who were also unaware of each other's translations. In order to evaluate the translations and ensure consistency, approval was also obtained from a sworn translator. In addition, official permission for the Turkish validity and reliability study was obtained from Adriana Hermida.