APA is preparing to publish a major revision of its guideline on the practice of electroconvulsive therapy (ECT) next year. The new edition will contain substantially updated recommendations, according to members of the task force in charge of revising the guideline.

Members of APA's Task Force to Revise the Practice of Electroconvulsive Therapy gave an update on the current evidence for the efficacy and safety of ECT at APA's 2009 annual meeting in San Francisco in May.

Clinical topics discussed by task force members included optimal electrode placement, informed consent and documentation, stimulus dosing, and relapse-prevention strategies. FIG1

The task force members have been reviewing the latest research evidence in weekly teleconferences and collecting feedback from clinicians for this revision, explained task force chair Sarah Lisanby, M.D., a professor of psychiatry at Columbia University and the chief of the Columbia Brain Stimulation and Therapeutic Modulation Division. The guideline will also contain proposals for training and certification for ECT practice, the task force members noted.

Charles Kellner, M.D., a professor of psychiatry at Mount Sinai School of Medicine, discussed the continuing debate over the optimal electrode placement. The current guideline recommends that practitioners "should be skilled in administering both unilateral and bilateral ECT," and the placement choice "should be based on an ongoing analysis of applicable risks and benefits" and on consultation with the psychiatrist, the person giving consent, and the attendant physician. In recent years, the use of bifrontal electrode placement has gained popularity, he noted.

In a recently completed study conducted by the Consortium for Research in ECT (CORE) and funded by the National Institute of Mental Health, 230 patients were randomized to receive right unilateral (RUL) ECT treatments at six times the seizure threshold, bifrontal (BF) ECT at 1.5 times the seizure threshold, and bilateral (BL) ECT also at 1.5 times the seizure threshold, Kellner said. The rates of remission were 55 percent for RUL, 61 percent for BF, and 64 percent for the BL treatment. The rates of response were 73 percent, 79 percent, and 82 percent, respectively. These results were not statistically significant among the treatment arms. Looking at the changes in symptoms over the treatment courses, however, "the bitemporal ECT gets patients well more quickly than the other two electrode placements," Kellner pointed out, and this difference was statistically significant.

Meanwhile, the cognitive effects of each placement require further research. "Although it is pretty clear that bilateral electrode placements are a little bit more effective than right unilateral, and right unilateral placement causes less cognitive impairment for many patients, we're still not able to predict exactly the outcome or side effects for a particular patient," he said. Kellner and most attendees agreed that, if a patient is severely ill, suicidal, or urgently needs symptom relief, bilateral ECT is a favored placement choice.

Another controversial issue is whether the electrode placement should be explicitly mentioned in the informed consent and whether informed consent should be obtained again if the placement is changed due to treatment failure. Attendees expressed divergent opinions based on their own ECT practice.

Since patients have different seizure thresholds, a titration-based stimulus dosing strategy, in which the electric charge applied for each patient is adjusted to his or her individual seizure threshold, is better than fixed-charge dosing, in which the same electric charge is given to every patient, according to Andrew Krystal, M.D., a professor of psychiatry at Duke University School of Medicine.

Some physicians use an age-based dosing algorithm to calculate the estimated seizure threshold before administering ECT rather than specifically titrating the electrical charge in each patient during the procedure. Because a higher charge above the seizure threshold is associated with a higher degree of cognitive side effects in both RUL and BL placements and people vary substantially in their individual seizure threshold, dosage titration is the more appropriate approach to optimize outcome, said Krystal.

Prior research studies have mostly used six to eight times the seizure threshold for RUL ECT. Krystal cited a 2002 study by W. Vaughn McCall, M.D., and colleagues indicating that RUL ECT given at eight times seizure threshold produced cognitive impairment and antidepressant effect similar to BL ECT at 1.5 times the seizure threshold.

Ultra-brief pulses given at 0.25 or 0.3 milliseconds are also an area of research interest, as this approach may produce efficacy similar to that achieved by conventional pulses (1.5 milliseconds) but may reduce cognitive side effects. Harold Sackeim, Ph.D., and colleagues conducted a study of 90 patients who were randomized to four groups that compared RUL with BL and ultra-brief pulse with standard pulse. Their results were published in the January 2008 Brain Stimulation.

The ultrabrief-pulse RUL ECT at six times the seizure threshold produced the highest remission rate (73 percent) and the least cognitive impairment compared with standard BL (2.5 times the seizure threshold), standard RUL, and ultrabrief BL. Unexpectedly, the patients on ultrabrief BL did the worst in terms of efficacy, with only 35 percent reaching remission. "It's an exciting, interesting emerging story," said Krystal, but a lot more evidence is needed to answer many questions about finding the best treatment with the lowest risk.

In addition, how to maintain the impressive response and remission rates after acute ECT and not lose ground to relapse remains an unresolved clinical question. Mustafa Husain, M.D., a professor of psychiatry and internal medicine at the University of Texas Southwestern Medical Center in Dallas, presented a 2007 study by CORE of 200 patients who had achieved remission after acute ECT. The patients were randomized to either maintenance ECT, gradually tapered to once a month, or to pharmacotherapy with lithium and nortriptyline. The six-month relapse rates did not differ significantly between the two treatments, with 32 percent on pharmacotherapy and 37 percent on maintenance ECT relapsing. Overall, 46 percent of patients on either treatment maintained their remission while the rest either relapsed or dropped out.

Other options for maintenance, such as combining maintenance ECT and pharmacotherapy and administering ECT as needed based on symptoms and algorithms, are being used in practice and need more study. Emerging neurostimulation treatments, such as transcranial magnetic stimulation, may offer additional options for relapse prevention, Husain said. ▪