Open Journal of Depression
2013. Vol.2, No.3, 17-18
Published Online August 2013 in SciRes (
Copyright © 2013 SciRes. 17
Editorial: Is Electroconvulsive Therapy a Therapy with Future?
Jérôme Palazzolo1,2
1International University Senghor, Ale xa ndria, Egypt
2Quai des Deux Emmanuel, Nice, France
Received June 7th, 2013; revised July 7th, 2013; accepted July 15th, 2013
Copyright © 2013 Jérôme Palazzolo. This is an open access article distributed under the Creative Commons At-
tribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the
original work is properly cited.
Although it was introduced almost 60 years ago, ECT still
plays a key role in the treatment of severe depression. Recent
clinical research has sought to refine treatment technique so as
to: 1) achieve an optimal balance between antidepressant ef-
ficacy and cognitive adverse effects; 2) address the specific
problems posed by elderly, medically ill patients; and 3) de-
velop adequate measures for the prevention of relapse in pa-
tients have responded.
Optimizing the Clinical Administration of ECT
When ECT is used as a first line treatment for depression, the
response rate is in the range of 80% - 90%. Among non-re-
sponders to antidepressant medication, efficacy may be as low
as 50% - 60%. Cognitive adverse effects remain the most im-
portant negative consequence of ECT. Although they resolve
within 6 - 8 weeks, their negative impact on public attitudes to
ECT is considerable. Accordingly, treatment modifications which
improve efficacy and reduce adverse effects are an important
Stimulus Waveform
It has been clearly shown that unmodified sine wave stimula-
tion is associated with considerably more severe cognitive ad-
verse effects than brief pulse stimulation. Consequently, all con-
temporary ECT devices employ a constant current, brief pulse
Electrode Placement
The majority of studies comparing unilateral (UL), non-do-
minant (right) and bilateral (BL) electrode placement have found
a lesser degree of cognitive impairment with UL placement. In
terms of antidepressant efficacy, studies which administer UL
treatment at a higher electrical dose have been more likely to
find this placement equivalent to BL.
A study1 which controlled for electrode placement as well as
stimulus intensity showed that UL ECT administered at a high
electrical dose (relative to the seizure threshold of each patient)
was inferior in outcome to both low and high dose BL. The
most rapid response wa s achieved with high dose BL. Low dose
UL was strikingly ineffective (17% response). BL placement
was associated with significantly greater cognitive deficits.
It has still to be established whether UL treatment at a higher
dose than administered in the Sackeim et al. (1993) study will
be as effective as BL ECT but at a lesser cost in terms of ad-
verse effects.
Stimulus Intensi ty
The concept of stimulus intensity dosing in ECT is relatively
new and still not universally applied. Two crucial observations
underscore its importance. The first is that individual patients
may vary by as much as 4 - 5 fold in their threshold for seizure
induction and the second is that in the majority of patients there
is a substantial increase in seizure threshold, of the order of
40% for UL ECT and 80% for BL ECT, during the ECT course.
Increasing age, male gender and bilateral electrode placement
are associated with higher seizure threshold but account for less
than half of inter-patient variability. Higher electrical dose is
associated with greater cognitive deficit. Therefore, it is logical
to individualize treatment so that the patient receives an elec-
trical dose which is sufficient to induce a therapeutically ade-
quate seizure but does not exceed threshold by more than is
required. Although still an approximation, the titration tech-
nique is the most accurate method for defining seizure thresh-
old during the first treatment. It is not associated with a greater
incidence of cognitive or cardiovascular adverse effects. For-
mulae based on the patient's age are also used. Subsequent
treatments are administered at a moderately suprathreshold
level (2 - 2.5 times threshold). It is essential to monitor seizure
duration during subsequent treatments so as to detect increases
in seizure threshold and alter electrical dose accordingly.
Treatment Schedule
Schedule of ECT administration is defined by the frequency
of ECT administration (usually twice (ECT x 2) or three times
(ECT x 3) weekly) and the number of treatments in the series
(usually 6 - 12). Cognitive adverse effects increase with fre-
quency and number of treatments.
Lerer et al.2 compared twice and three times weekly BL ECT
in the context of a double blind study which balanced treatment
frequency by the use of simulated ECT in the ECT x 3 group.
Antidepressant response was more rapid with ECT x 3 although
the schedules were equal in final outcome. ECT x 3 was associ-
ated with greater memory impairment. These results were con-
1Sackeim H. A. et al.—New England Journal of Medicine, 1993, 328, 839-
846. 2Lere r B. et al.
America n Jou rnal Psychia t ry, 1995, 152, 564-570.
firmed in a further double blind study (Shapira et al., submitted)
which showed that the more severe cognitive side effects of
ECT x 3 are a consequence of the greater frequency of ECT
administration independent of the number of treatments admin-
istered. Unless speed of antidepressant effect is an overriding
consideration, twice weekly ECT should be preferred, at least
in the case of BL treatment.
ECT and the Medically Ill Patient
An increasing proportion of patients referred for ECT are
elderly and manifest a variety of medical illnesses of which
hypertension, ischemic heart disease and other cardiovascular
disorders most frequently place the patient in the high risk
category. Such patients require careful evaluation and monitor-
ing. ECT typically induces bradycardia which is due to vagal
stimulation and then strong sympathetic stimulation with tachy-
cardia and increased blood pressure. Administration of atropine
immediately prior to ECT prevents the bradycardia and is gen-
erally recommended although some studies question its efficacy
and safety. In hypertensive patients blood pressure should be
carefully controlled. Some studies find administration of a short
acting beta blocker immediately before ECT to be effective.
Post ECT Continuation Treatment
Without continuation treatment the relapse rate of patients
who have responded to ECT may exceed 80%, most in the first
4 months after the series. In contemporary ECT practice, most
of the patients referred for ECT are antidepressant non-respon-
ders. Continuation treatment with the same class of agents to
which the patient had been refractory before ECT, has been
criticized as illogical. Indeed, 50% of patients who were re-
fractory to antidepressants before ECT relapse on these agents
during the continuation phase. Novel approaches are clearly
needed. Shapira et al.3 found that 6 month survival without
relapse was 65% in patients who were continued on lithium
after responding to ECT. Continuation ECT is an alternative for
patients with a strong history of relapse. Its efficacy and safety
have been supported by small studies.
There is still no viable alternative to ECT for patients with
depressive illness which has not responded to antidepressant
drugs but requires rapid treatment. Careful attention to the find-
ings of recent clinical research can increase the safety of the
treatment and enhance its efficacy.
3Shapira B. et al.—Convulsi ve Therapy, 1995, 11, 80-85.
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