Study Compares Potential MDD Treatment DANA Against Standard MMSE

The Defense Automated Neurobehavioral Assessment (DANA) has been validated against the standard Mini-Mental State Examination (MMSE) shown as a sensitive and practical tool for measuring cognition in depressed patients undergoing electroconvulsive therapy (ECT) treatment for major depressive disorder (MDD).

Researchers recruited 17 patients with depression from the Johns Hopkins Hospital Department of Psychiatry receiving ECT after standard pharmacological interventions failed.

“We chose ECT because some people say it affects cognition, and some people think it doesn't,” Adam Kaplin, PhD, study co-author said.

Patients undergoing ECT therapy are routinely given the MMSE to make sure cognition isn’t being affected by the treatments and if the MMSE shows it is, clinicians will skip treatments.

“The MMSE is a well-validated cognitive test made up of 11 questions to assess orientation, memory, attention, calculation, recall, and language,” write the authors.

It’s used to monitor patients undergoing ECT at Johns Hopkins, and is administered via paper and pencil. Although the MMSE is the standard, and is a well-validated, widely used cognitive test, it has a maximum score, which creates a ceiling. Kaplin noted someone like Einstein could be cognitively impaired but still repeatedly score 30 on the MMSE, insinuating clinicians need a more sensitive assessment.

The DANA battery of tests include reaction time (RT), procedural reaction time (PRT), code substitution (CS), spatial processing (SP), and memory search (MS). It’s conducted on an electronic tablet and, importantly, there is no ceiling score.

Researchers state 2 objectives for the current study: measure the relationship between DANA and Mini-Mental State Examination (MMSE) scores, and measure cognitive changes over time using DANA and MMSE in subjects with MDD undergoing ECT treatment.

There were 3 main findings in the current study. First, researchers found what they describe as “significant relationships between MMSE and DANA scores.” Second, they found that removing the ceiling effect of the MMSE, the relationship between DANA and MMSE scores improved. The third finding was that MMSE and DANA scores change over time in patients undergoing ECT.

“One-half of the MMSE scores recorded in the present study were perfect scores of 30,” researchers said. “Exclusion of these and their associated DANA scores revealed significant relationships between MMSE and DANA scores on all 5 subtests.”

“It was interesting that some subjects experienced cognitive impairment whereas others made it through their ECT treatments with cognitive domains intact or even improved,” noted the researchers. They suggest this could be due to the association between cognitive impairment and depression.

The authors concluded their study validated the DANA against the MMSE, which is a widely used and recognized cognitive assessment.

“It was validated, but also even better, it was more sensitive and picked up things the mini didn't pick up,” says Kaplin, adding, “people had 30 out of 30 and still had some changes.” While the DANA may pick up on less important characteristics, it’s better to have a tool too sensitive.

However, Kaplin thinks the DANA may be too sensitive, noting some patients scored 30 on the MMSE, but did worse on the DANA assessments. “Is that clinically relevant? How long does it take to recover?” he asks.

Future studies will compare MMSE domain subscores with the corresponding DANA subtest results, and should focus on patients who are receiving equal numbers of ECT treatments.

The full study, titled, “Defense Automated Neurobehavioral Assessment Accurately Measures Cognition in Patients Undergoing Electroconvulsive Therapy for Major Depressive Disorder” can be found in the Journal of ECT.