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Titrated Moderately Suprathreshold vs Fixed High-Dose Right Unilateral Electroconvulsive Therapy
Acute Antidepressant and Cognitive Effects
W. Vaughn McCall, MD, MS;
David M. Reboussin, PhD;
Richard D. Weiner, MD, PhD;
Harold A. Sackeim, PhD
Arch Gen Psychiatry. 2000;57:438-444.
Background The antidepressant and cognitive side effects of right unilateral (RUL) electroconvulsive therapy (ECT) are reported to depend on the magnitude of the electrical stimulus relative to the seizure threshold. The stimulus doses explored in previous clinical trials of RUL ECT have generally been limited to 1 to 2.5 times the convulsive threshold and the antidepressant efficacy has been low compared with bilateral (BL) ECT. The present study compares the antidepressant and cognitive side effects of 2 RUL dosing strategies: titrated moderately suprathreshold and fixed high dose.
Methods Seventy-two adult patients with major depression were randomized to either titrated RUL ECT at 2.25 times initial seizure threshold (mean dose, 136 millicoulombes [mC]), or RUL ECT at a fixed dose of 403 mC. Primary outcome measures were antidepressant response and cognitive status 1 or 2 days after the course of ECT.
Results The 2 treatment groups were comparable in demographic and clinical characteristics prior to ECT. Both groups received a mean of 5.7 sessions of RUL ECT. Patients receiving fixed-dose ECT were more likely to have an antidepressant response at the end of the protocol (n=49 [67%]) compared with those receiving titrated dosing (n=28 [39%]). Furthermore, the likelihood of both antidepressant response and cognitive deficits increased as stimulus dose increased relative to initial seizure threshold, up through 8 to 12 times the threshold.
Conclusions The antidepressant efficacy and cognitive side effects of RUL ECT are dependent on the magnitude of the stimulus dose relative to the seizure threshold, and a dose-response relationship extends through at least 12 times the seizure threshold.
From the Departments of Psychiatry and Behavioral Medicine (Dr McCall) and Public Health Sciences (Dr Reboussin), Wake Forest University School of Medicine, Winston-Salem, NC; the Department of Psychiatry, Duke University School of Medicine and the Department of Veterans Affairs Medical Center, Durham, NC (Dr Weiner); and the Departments of Psychiatry and Radiology, College of Physicians and Surgeons, Columbia University, and the Department of Biological Psychiatry, New York State Psychiatric Institute, New York (Dr Sackeim).
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