Effective Use of Electroconvulsive Therapy in Late-Life Depression
In recent years, our understanding has progressed substantially regarding
the effect of technical factors on ECT’s efficacy and side effects. Based
on current data, several recommendations can be made about the administration
of ECT to older patients. First, to optimize efficacy and minimize cognitive
side effects, it is important to individualize the dose of electricity.
The most precise way to do this is to determine a patient’s seizure threshold
by means of stimulus dosing. Second, the choice of high-dose (at least
6 times seizure threshold) RUL vs low-dose (1.5 times seizure threshold)
bitemporal ECT should be made on a case-by-case basis. Patients who have
neurological conditions that may increase their vulnerability to the cognitive
side effects of ECT are candidates for RUL treatment—assuming that the
patient’s seizure threshold allows an efficacious dose of unilateral ECT,
not only at the start of treatment but also as treatment progresses (bearing
in mind that seizure threshold increases during the course of treatment,
especially in older patients). Low-dose bitemporal ECT should be considered
in the following patients: those who have previously responded to bitemporal
treatment but not to high-dose unilateral treatment; those who are so sick
that the most definitive treatment is needed (for example, for a stuporose
patient refusing food or fluid); those whose cardiovascular or other medical
concerns mandate the fewest possible treatments; and those whose seizure
threshold precludes efficacious unilateral treatment. Based on these considerations,
it is apparent that bitemporal electrode placement will be indicated for
many elderly patients undergoing ECT. Further research is needed to determine
whether bifrontal ECT has clinically significant advantages over bitemporal
or high-dose RUL treatments in older patients. Third, twice-weekly administration
appears to be the optimal schedule for bitemporal ECT in the elderly, unless
other considerations require the more rapid antidepressant effect of thrice-weekly
treatment. The relative merits of twice- vs thrice-weekly administration
of RUL ECT in older patients have yet to be established. Finally, because
there is considerable interindividual variability in the number of ECT
treatments required for response, the number of treatments in a course
of ECT should be decided on a case-by-case basis. If a patient is showing
slow but ongoing improvement, there is no reason to stop at 12 treatments.
Despite advances in the administration of ECT, relapse of depression remains
a significant problem. The logical solution is to continue with ECT beyond
the acute phase of treatment, yet there are several barriers to the routine
use of continuation ECT. The challenge facing researchers is to determine
whether any other approaches to treatment can minimize the risk of relapse.
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Manuscript received and accepted August 2002.
1 Professor of Psychiatry, University of Toronto; Head, Geriatric Psychiatry
Program, University Health Network, Toronto, Ontario.
2 Research Fellow, Department of Psychiatry, University of Toronto, University
Health Network, and Toronto Rehabilitation Institute, Toronto, Ontario.
Address for correspondence: Dr Alastair Flint, Toronto General Hospital,
200 Elizabeth Street, 8 Eaton North–Room 238, Toronto, ON M5G 2C4
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