Optimizing ECT.

Optimizing the safety and the efficacy of a treatment course has been a persistent goal of ECT practice since its introduction sixty years ago. Muscle relaxants, barbiturate anesthesia, and oxygenation were developed to reduce the risks of fracture, fear, and cognitive deficits. Unilateral electrode placement elicited fewer cognitive complaints and was reported as clinically effective as bilateral placement. Seizure duration monitoring, first by cuff and then by EEG, was introduced to define "an effective seizure". Caffeine pre-treatment lengthened seizure durations. Brief pulse square wave currents replaced sinusoidal currents to reduce cognitive effects. Twice weekly treatments were shown to be as effective as three treatments weekly, although the latter was more rapidly effective. Continuation ECT became a feature of practice. The safety and efficacy of psychoactive drugs combined with ECT were clarified so that antipsychotic drugs now are generally continued; benzodiazepines, lithium, and anticonvulsants are withdrawn; and the continuation of antidepressant drugs is optional. In recent studies, the minimal energy needed to elicit a seizure was determined and energy dosing is suggested as 2.5 times [or other multiple] of the threshold. Others find that age or half-age dosing methods are satisfactory and with less risk to patients. The definition of an "effective seizure" as one that is 25 seconds or longer in motor convulsive activity is questioned and EEG criteria are examined as substitutes.(ABSTRACT TRUNCATED AT 250 WORDS)