ECT: brief pulse v ultra brief pulse

There are few women among the big names of electroconvulsive therapy (ECT). One of the few is Australian psychiatrist Colleen Loo: “an active clinician and researcher, with a particular interest in electroconvulsive therapy (ECT) and novel treatments for mood disorders, including Transcranial Magnetic Stimulation (TMS), transcranial Direct Current Stimulation (tDCS) and ketamine” (from her page at Black Dog Institute). Colleen Loo has been courting publicity recently for her latest publication, a review of six studies of ultra-brief pulse right unilateral ECT compared to brief-pulse right unilateral ECT. The paper was written by Professor Loo and five other psychiatrists and looked at six studies of the short-term effects of the treatments. Their conclusions (from the abstract – I am not sure if the paper is actually published yet):

“BP compared with UBP RUL ECT was slightly more efficacious in treating depression and required fewer treatment sessions, but led to greater cognitive side effects. The decision of whether to use BP or UBP RUL ECT should be made on an individual patient basis and should be based on a careful weighing of the relative priorities of efficacy versus minimization of cognitive impairment.” (A systematic review and meta-analysis of brief versus ultrabrief right unilateral electroconvulsive therapy for depression by P.C. Tor et al., Journal of Clinical Psychiatry , 2015 Jul 21. [Epub ahead of print].)

There doesn’t seem to be anything very newsworthy there. Anything that reduces the damaging effects of ECT also tends to reduce the desired effects as well. That has been known for a long time. Neither is there is there anything new about ultra-brief pulse ECT. It has been around since the 1940s. But Professor Loo has put out a press release describing it as a “new treatment” that “is one of the most significant developments in the clinical treatment of severe depression in the past two decades”. She hopes “the study will result in an improved uptake of the new treatment for people with severe depression.”

Adjusting the pulse width does not change the fact that patients are being given a powerful electric shock – current strength remains the same. But that doesn’t deter sciencealert.com for example from talking about a “new, gentler ECT” and “tiny pulses of electric current”.

The debate about pulse-width is of no relevance to people who are given bilateral rather than unilateral ECT, and in many countries including the UK bilateral remains the most common form of ECT.

Meanwhile a team of psychiatrists in the Netherlands and Belgium have published a paper looking at longer-term effects of ultra-brief pulse and brief-pulse unilateral ECT. (Relapse and long-term cognitive performance after brief pulse or ultrabrief pulse right unilateral electroconvulsive therapy: A multicenter naturalistic follow up, by E. Verwijk et al., Journal of Affective Disorders, September 2015) Their conclusions:

“Patients that achieved remission after RUL BP or RUL UBP ECT showed similar relapse rates after three and six months. There was no cognitive advantage of UBP over BP ECT in follow up.”

Again, there is little to justify headlines about a new type of ECT. What was striking was how few of the people who started courses of unilateral ECT (whatever the pulse width) were considered to have recovered from depression and not to have relapsed within six months – just 13 out of 58 in each group (or 55/54 if you don’t count the 3 or 4 people lost to follow up). Some people were switched to bilateral, others didn’t want to continue with ECT, others became confused or manic or had to stop treatment because of other complications. Of those who completed the course, 26 out of 38 in the BP group, and 24 out of 49 in the UBP were considered remitted, and then over the next six months 43.5 per and 35 per cent respectively had relapsed. The article didn’t give the age and sex of those who began ECT, but those who completed the course and were considered to have remitted had a mean age of 67 with 80 per cent of them being women. Both groups were given up to 12 treatments at eight times seizure threshold, the difference in pulse width being 0.3-04 milliseconds in the ultra-brief pulse group compared to 1 millisecond in the brief pulse group.

ECT in the Netherlands nearly disappeared in the 1970s but its use has increased since then and Dutch psychiatrists seem to be prolific when it comes to publishing research on ECT.

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