The Ideal ECT Technique or the Ideal ECT Patient: What Should Be the Focus of Research?

Abstract

T he endeavor of Tor and colleagues 1 confirms the buzz that has been around for some time. Ultrabrief pulse (UBP) right unilateral (RUL) electroconvulsive therapy (ECT) is an attractive ECT technique, since it has a strong reputation of being cognitively safe. Its antidepressive efficacy, however, is less robust than that of standard brief pulse (BP) ECT. In a meta-analysis of 6 studies, comprising a total of 689 patients, Tor et al conclude that standard BP unilateral ECT is, indeed, significantly more efficacious than UBP ECT. The latter yields lower remission rates, with a number needed to treat of 12.1. BP RUL ECT, however, has significantly more cognitive side effects.Although the delicate balance between efficacy and side effect burden is not yet fully detailed, a substantial number of clinicians and clinics have made the transition toward the use of UBP ECT. Even in the most severely ill patients, those with chronic catatonia, this technique is advocated. [2][3][4] Interesting naturalistic data on the use of UBP ECT recently presented by Galletly and colleagues 5 shed some light on the possible consequences of changing treatment protocols. In a private psychiatric hospital, after the introduction of UBP ECT, patients received 2 treatment sessions more in a course and spent on average more than 5 days longer in the hospital with this technique compared to BP ECT. A lower proportion of the patients responded to the treatment (54% vs 66.7%). These findings align with those of the meta-analysis, 1 in which patients treated with UBP ECT received a significantly higher number of treatment sessions (9.6 vs 8.7) than patients treated with BP ECT.It seems that the field has shifted from preferring highly effective techniques and accepting the cognitive burden toward focusing on reducing cognitive side effects, even if the price is reduced efficacy. A similar evolution was seen in psychopharmacology, in which side effects of tricyclic antidepressants and lithium have been consistently exaggerated and their efficacy underestimated, while the opposite happened with the newer antidepressants. We should, nevertheless, continue to use the most efficacious treatment options, such as tricyclics, lithium, and bilateral standard pulse ECT, for our patients. It is of importance to note that most side effects of ECT are transient. 6 Sacrificing efficacy to avoid these transient side effects is perhaps not the best strategy to consider in some of the most severely ill patients we have under our care. As is shown in Tor and colleagues' meta-analysis, UBP ECT should not be the standard of care.In our clinic, where we have studied UBP ECT, 7-9 this technique is not used routinely. In selected cases in which avoiding cognitive side effects is a primary consideration, UBP ECT is a useful treatment alternative. An example is the case of a teacher who was treated for severe depression with suicidality that swiftly remitted with BP bifrontal ECT after several failed medication trials. After he relapsed, he refused a second course bec...

What Can We Tell About the Effect of Electroconvulsive Therapy on the Human Hippocampus?

“…34 The adjustment of ECT techniques for each individual is critical. For instance, it may not be the best strategy to sacrifice efficacy to avoid transient cognitive side effects in severely ill patients, 35 such as those with life-threatening conditions (such as catatonic stupor or refusal to eat and drink) who require a rapid recovery.…”