Evaluation of Changes in Balance After the First Electroconvulsive Therapy in Patients Diagnosed with Major Depressive Disorder

1. Introduction

Major depressive disorder (MDD), the most common mental illness in the world, is a serious health problem. In addition, a large proportion of suicides are associated with a diagnosis of MDD [1]. Despite its high prevalence, major depressive disorder continues to pose substantial treatment challenges. MDD is often a chronic and progressive illness. Depression is a state of not enjoying life that negatively affects an individual's life over a long period of time. People with depression experience negative emotions such as hopelessness, worthlessness, guilt, and loneliness [2].

Major depressive disorder is defined as having at least one major depressive episode with no history of manic or hypomanic episodes. The main feature of a depressive episode is a period of at least two weeks in which depressed mood or a loss of interest or pleasure in activities occurs most of the day or almost every day. Its annual prevalence in the United States is shown as 7%. Although it differs according to age groups, it is defined as three times more prevalent in individuals between the ages of 18-29 compared to individuals over 60 years of age. It is twice as common in women as in men, especially during menarche and menopause. Recurrent findings may be seen in the diagnosis of major depression disorder [3]. About 60% of people with MDD will experience relapses, and each successive episode has a 10-20% chance of not being in remission with current treatments [4]. In the Chronic Diseases and Risk Factors Study in Turkey, the prevalence of depressive disorder was reported as 6% in men, 12% in women, and 9% in the total population. The prevalence of depressive complaints in women was found to be twice as high as in men. [5].

Electroconvulsive therapy (ECT) is commonly used in the treatment of MDD. ECT is the process of inducing generalized seizures by electrically stimulating brain tissue and has been used as an effective tool in the treatment of mental disorders since 1938 [6]. ECT, mainly used in the treatment of depressive disorders; although it has been partially replaced by drug treatments, it is accepted that ECT is the fastest and most effective treatment. The use of ECT is particularly recommended in cases of risk of suicidal ideation, psychotic manifestations, in the absence of oral nutrition, in cases of inadequate drug therapy, in cases of with a history of good response to ECT, in dysthymia, if the risks to standard antidepressant treatment based on individual patient preferences are high [7].

While cognitive adverse effects of electroconvulsive therapy are well recognized, its influence on motor function and balance remains less clear [8]. Previous investigations have reported inconsistent findings regarding postural stability following treatment. Although the cognitive adverse effects of electroconvulsive therapy have been extensively investigated, limited evidence is available regarding its acute effects on balance and postural control. Existing studies are scarce and have primarily focused on older adults, leaving uncertainty regarding balance impairment in patients undergoing their first electroconvulsive therapy session. If we consider the side effects of ECT; memory disturbances lasting up to 6 months manifest as arrhythmias, headaches, muscle aches and associated balance disturbances [10,11].

Balance impairment following electroconvulsive therapy may compromise patient safety by increasing susceptibility to falls during the immediate post-treatment period. However, evidence regarding the magnitude and temporal profile of this impairment remains limited. Therefore, the aim of the present study was to investigate short-term changes in balance following the first electroconvulsive therapy session in patients with major depressive disorder.

2. Materials and Methods

This prospective observational repeated-measures study was conducted in patients with major depressive disorder undergoing first-time electroconvulsive therapy. Patients diagnosed with MDD who applied to the psychiatry service of a private hospital were included in the study. Ethical approval was obtained from the Medical Ethics Committee of Private French Lape Hospital (Approval No. 2018/4, 26 December 2018). Participants, who signed informed consent forms, were included in the study. The inclusion criteria were voluntary participation, a diagnosis of major depressive disorder confirmed by a psychiatrist, first-time electroconvulsive therapy treatment, and age between 18 and 65 years. Exclusion criteria were a diagnosis of any vestibular or neurological disease. A total of 22 participants, 7 women and 15 men, were included in the study. Post hoc power analysis was performed using G*Power version 3.1 and revealed a statistical power of 88%. All participants underwent electroconvulsive therapy according to the institutional treatment protocol. Electroconvulsive therapy was administered using a Thymatron IV device (Somatics LLC, Lake Bluff, IL, USA) with bilateral electrode placement. The procedure was performed under general anesthesia with respiratory support. Anesthesia was induced using either sodium thiopental or propofol, and succinylcholine was administered for neuromuscular relaxation. Seizure duration ranged from 25 to 50 seconds. Prior to treatment, patients received standardized instructions regarding the procedure and were informed about potential complications. After the demographic information was obtained, their balance was evaluated using the BBS [12]. The BBS is a validated 14-item instrument widely used to evaluate functional balance and fall risk in adults. It is used to assess the ability to maintain balance during physical activities. The Turkish validity and reliability of the scale was performed by Şahin et al. [11]. Participants were evaluated a total of 3 times; at baseline (prior to ECT), 1 hour after treatment, and 24 hours after treatment. all participants completed the follow-up assessments.

The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Generative artificial intelligence was not used in the study design, data collection, data analysis, interpretation of results, or manuscript preparation. Copilot used only for text editing.

Statistical Analyses

IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA) for Macbook was used in the data analysis of the study. Descriptive statistics were given as mean, standard deviation and percentage distribution. Changes in BBS scores across the three assessment time points were analyzed using repeated-measures analysis of variance with Bonferroni-adjusted pairwise comparisons. Significance level was accepted as p<0.05.

3. Results

Twenty-two participants (7 women and 15 men) were included in the study. The mean age of the participants was 34.45 ± 14.38 years. Descriptive results are presented in Table 1.68.2% of the participants were male and 31.8% were female. The mean age is 34.45± 14.38 years. The mean age and mean BBS scores are given in Table 1.

The Bonferroni correction after One-Way Analysis of Variance (ANOVA) to determine the change in BBS Scores according to ECT time is shown in Table 2.

When the time-dependent variation of the effect of ECT on the balance was analysed, significant effect of time on BBS scores was observed (F=597.17, p<0.001). BBS scores decreased significantly from baseline to 1 hour after ECT (mean difference = 14.82, p < 0.001) and increased significantly between the 1-hour and 24-hour assessments (mean difference = 14.64, p < 0.001). No significant difference was found between baseline and 24-hour measurements (p=0.640).

4. Discussion

In this study, we investigated the early effects of first-time electroconvulsive therapy (ECT) on balance. The results indicated a significant impairment in balance one hour following ECT. Although marked balance impairment was observed one hour after ECT, balance performance had largely returned to baseline levels by 24 hours following treatment. These findings suggest that the first hour following ECT represents a period of increased vulnerability to postural instability and may warrant implementation of fall-prevention measures.

Plakiotis et al. in their study with 21 participants; they evaluated balance and gait before, 1 hour, 2 hours, and 3 hours after ECT. Their evaluations parameters are steady standing test, arm raise test, step test and time up and go test [10]. In their study, they reported that they did not encounter a fall after ECT, but they encountered participants with significant balance problems. For this reason, they concluded that regular assessment of balance and gait would be appropriate for the application of ECT. We evaluated the balance only with BBS in our study. Although the evaluation parameters are different; similar results were obtained when compared with our study.

ECT greatly affects the brain and cerebellum. Their neural connections can also be demonstrated in fMRI studies. Fu et al. evaluated functional neural network connectivity following ECT and demonstrated significant alterations in cerebro-cerebellar functional connectivity associated with both cognitive outcomes and treatment response [12,13]. The transient balance impairment observed one hour after electroconvulsive therapy may be partly explained by residual post-anesthetic sedation and temporary disruption of sensorimotor integration. ECT is commonly performed under general anesthesia using hypnotic agents and neuromuscular blockade, both of which may contribute to short-term alterations in postural control and motor performance. In addition, electroconvulsive therapy induces acute changes in large-scale neural network activity, and these transient functional alterations may temporarily affect the integration of vestibular, proprioceptive, and visual sensory information required for maintaining balance [14].

The significant deterioration in Berg Balance Scale scores observed in our study during the first post-treatment hour may therefore reflect a combination of post-anesthetic effects and acute disturbances in sensorimotor processing [14]. These findings are consistent with previous reports demonstrating that electroconvulsive therapy may influence both cognitive and motor networks during the early post-treatment period [13,14]. Jolly and Singh, in their study, concluded that cognitive functions returned within two weeks after ECT and did not leave permanent damage, as demonstrated by long-term fMRI studies [15]. Consistent with these findings, our study demonstrated transient balance impairment during the early post-treatment period, suggesting that acute functional changes following ECT may extend beyond cognition and affect postural control. The relationship between cognitive functions and balance can also be explored with another study design.

Another potential mechanism involves transient modulation of cerebro-cerebellar networks. Recent neuroimaging studies have demonstrated that ECT induces functional neuroplastic changes in cerebellar and cortical connectivity, and alterations in these networks have been associated with both cognitive outcomes and clinical response. Because the cerebellum plays a critical role in postural control, vestibular processing, and movement coordination, temporary changes in cerebellar functional connectivity may contribute to the short-term balance disturbances observed after treatment [13,16]. Interestingly, clinical studies have reported improvements in motor symptoms following ECT in neurological disorders such as Parkinson's disease, suggesting that electroconvulsive therapy can substantially modify motor network function [17]. While these neuroplastic effects may be beneficial in the long term, our findings suggest that acute reorganization of cerebellar and sensorimotor networks may initially manifest as transient postural instability [13,16]. Further studies incorporating instrumented balance assessments and neuroimaging techniques are needed to clarify the relationship between cerebro-cerebellar plasticity, vestibular processing, and balance performance following ECT.

In our study, balance was assessed using the Berg Balance Scale (BBS), a tool widely utilized in clinical settings due to its simplicity, cost-effectiveness, and practicality [18] . Despite its broad acceptance and proven utility, recent literature underscores the limitations of relying exclusively on a single functional scale to identify subtle impairments in postural control. Emerging research indicates that instrumented assessments of postural sway and sensor-enhanced mobility evaluations—such as the Timed Up and Go (TUG) test integrated with inertial sensors or force plate technology—demonstrate superior discriminatory power. These advanced approaches enable a more nuanced and comprehensive evaluation of balance and mobility deficits, particularly in populations where subtle motor impairments may not be captured by conventional clinical scales [19,20,21].

The present study focused on the short-term effects of ECT on balance performance. Although assessments conducted at 1st and 24th hours post-intervention provide valuable insight into the acute impact of ECT, they fail to capture the medium- and long-term trajectory of post-treatment changes. Evidence from longitudinal research suggests that balance parameters may continue to evolve over subsequent weeks and even months. Although not specific to ECT populations, longitudinal studies of postural stability suggest that balance-related outcomes may continue to evolve over extended follow-up periods. Accordingly, future investigations should incorporate additional follow-up time points, such as 48 hours, 1 week, and beyond, to more comprehensively elucidate the persistence, recovery, or potential compensatory adaptations in balance following ECT [22,23].

In their study, Goegan et al. found that depression and disability symptoms improved significantly following ECT and these improvements continued 12 months after ECT [24]. Goegan et al. concluded in their study that it is effective for major depression, but more comprehensive studies will be done for cognitive functions. Despite the well-established effectiveness of ECT, potential adverse effects should continue to be carefully evaluated in order to optimize patient safety. In his research, Andrade stated that fractures of bones and teeth could occur during seizures when ECT is performed. Although fractures associated with electroconvulsive therapy are uncommon in contemporary practice, musculoskeletal injuries remain a potential concern [25]. Therefore, the transient balance impairment observed after ECT may have clinical relevance, particularly regarding patient safety and fall prevention.

In contrast, some reports have suggested beneficial effects of electroconvulsive therapy on motor function. Hobert et al. described a patient with major depressive disorder and multiple neurological comorbidities who demonstrated improved gait and independent ambulation following a multidisciplinary treatment program that included ECT [26]. Similarly, Roane et al. reported improvements in balance and gait parameters following ECT in patients with multiple system atrophy [27]. Although these findings suggest that ECT may positively influence motor function in certain neurological conditions, the evidence is limited to case reports and small case series. Therefore, larger studies are needed to clarify the effects of ECT on balance and motor control.

In their study investigating the use of ECT in older adults, Chatham et al. observed improvements not only in non-motor symptoms—particularly in patients with Parkinson's disease—but also short-term improvements in motor symptoms [28]. Similarly, Kennedy et al., in their study evaluating the efficacy of ECT in movement disorders, found a reasonable level of evidence supporting its positive effects on such disorders [29]. These findings further support the notion that ECT may influence neural systems involved in motor control, although the short-term effects observed in our study appear to manifest as transient postural instability rather than immediate motor improvement.

From a clinical perspective, the marked decline in balance observed during the first hour after ECT highlights a potentially vulnerable period for patient safety. Despite recovery by 24 hours, the substantial reduction in BBS scores immediately after treatment suggests that unsupervised mobilization may not be appropriate during the early post-treatment phase. Accordingly, supervised ambulation and fall-prevention strategies should be considered until postural stability has adequately recovered.

Several limitations of this study should be acknowledged. First, although post hoc power analysis demonstrated adequate statistical power, the sample size was relatively small, which may limit the generalizability of the findings. Second, the study was conducted at a single center, and therefore the results may not be representative of all patients undergoing ECT. Third, the absence of a control group prevented differentiation between the effects of ECT and those related to general anesthesia or post-anesthetic sedation. Consequently, the contribution of anesthesia to the observed balance impairment cannot be excluded. Fourth, balance was evaluated using only the BBS, and more sensitive instrumented assessments of postural control, gait performance, and mobility were not performed. In addition, gait parameters and fall incidence were not directly assessed, limiting the ability to draw conclusions regarding actual fall risk. Additionally, all participants underwent their first ECT session; therefore, the findings may not be generalizable to patients receiving maintenance or repeated ECT treatments. Finally, the follow-up period was restricted to 24 hours after treatment and did not allow evaluation of medium- or long-term changes in balance performance. Future studies including larger multicenter cohorts, appropriate control groups, objective balance and gait measures, and longer follow-up durations are needed to confirm and extend the present findings.

5. Conclusions

In conclusion, this study demonstrated a marked but transient impairment in balance during the first hour following electroconvulsive therapy. Although balance performance largely recovered within 24 hours, the early post-treatment period may represent a time of increased vulnerability to postural instability and falls. These findings highlight the importance of appropriate safety precautions and supervised mobilization following ECT. Further studies with larger samples, objective balance measures, and longer follow-up periods are needed to clarify the mechanisms and clinical significance of post-ECT balance impairment.