In this issue of the Nordic Journal of Psychiatry [Citation1] show that pulsewidth has no effect on quality of life after ECT; quality of life (QOL) improves with any pulsewidth ECT. This is not surprising, given that QOL is a blunt measure and ECT is so effective that most techniques work quite well. Is QOL a proxy for preserved antidepressant efficacy, or preserved cognition, or both? It would be most helpful to have data on depression symptoms and cognitive outcomes from the Swedish register, as well as the QOL data [Citation2].
That said, the manipulation of pulsewidth in ECT is aimed at improving the tolerability of ECT, by decreasing cognitive effects. A modest amount of research suggests that lower pulsewidths are associated with fewer acute cognitive effects [Citation3]; ultrabrief pulsewidths (<0.5 ms) have gained wide popularity based on this research. It is very clear that ultrabrief pulsewidths make seizure elicitation easier; that is, they allow seizure threshold (ST) to be lower [Citation4]. If we accept the premise that the antidepressant efficacy is linked to stimulus dose in relation to ST, then ‘fully effective’ seizures may be elicited with lower total stimulus charge, when using ultrabrief pulsewidths as part of the stimulus package.
Unfortunately, some of the data on ultrabrief pulse ECT indicate that it may have less or slower antidepressant efficacy than brief pulse ECT [Citation3,Citation5]. It is imperative to decide whether such a tradeoff is reasonable, and for whom. While the safety and antidepressant/antipsychotic efficacy of traditional forms of ECT (bilateral electrode placement, brief pulse stimuli) are proven beyond doubt, suboptimal tolerability issues, mainly acute and longer-term cognitive effects, continue to tarnish the reputation of ECT. In fact, it would not be an exaggeration to say that the issue of cognitive tolerability of ECT has dominated ECT research and practice for at least the past three decades. While it is obviously commendable to strive to develop the most benign treatment profile, it is likewise clearly not prudent to jeopardize efficacy for patients with potentially lethal psychiatric illness. This balancing act leads us to the basic concept of what is now called ‘personalized’ medicine; that is, the tailoring of the specific treatment to the individual patient. Thus, for patients with non-urgent or non-life-threatening depressive illness, it might be reasonable to opt for a ‘weaker’ form of ECT, particularly for patients with major concerns about avoiding transient cognitive adverse effects. On the other hand, urgently ill depressed patients (or seriously depressed patients with severe comorbid medical problems) deserve the most rapidly effective form of ECT, and tolerability issues are reasonably of secondary concern. Many such patients will be elderly and with few treatment options other than ECT for definitive relief.
Because standard technique ECT is the most potent antidepressant treatment ever developed, it stands to reason that our most severely and urgently ill patients should be offered such treatment. If only a fraction of patients referred for ECT meet such criteria, that leaves room for the substantial remaining portion of patients with ‘major depression’ to receive less powerful but better tolerated forms of ECT, foremost among them right unilateral ultrabrief pulse ECT. Just as ketamine and rTMS now nibble around the less ill fringes of a core group of ECT-appropriate patients, so, too, ultrabrief pulse ECT may be quite well suited to this cohort [Citation6]. Let us be vigilant, however, not to jeopardize ECT’s standing as the most effective antidepressant modality in the history of psychiatric treatment; by all means, try to balance efficacy and tolerability, but keep that the order of priority for those who are desperately in need of cure.
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Additional information
Notes on contributors
Charles H. Kellner
Charles H. Kellner, M.D. is a geriatric psychiatrist who has specialized in ECT and ECT research. He is a former Editor-in-Chief of the Journal of ECT and has published over 300 articles, mostly related to ECT. He is the author of Handbook of ECT from Cambridge University Press.
Martin Balslev Jørgensen
Martin Balslev Jørgensen is a chief physician at the Psychiatric Center, University Hospital Copenhagen, and a professor at the Department of Clinical Medicine, UCPH.
References
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