Brief vs. ultrabrief pulse ECT: focus on seizure quality

The effect of electroconvulsive therapy (ECT) performed with ultrabrief pulse (UBP) stimulation has been found inferior to brief pulse (BP) ECT in various studies. We reinvestigated this issue using a new dosing strategy that is based on seizure quality instead of seizure threshold. There is a long history of studies associating ictal characteristics of ECT with the clinical outcome. Accordingly, we used the clinical status of the patient and the quality of the prior seizure to determine the dosage for the upcoming treatment-referred to as Clinical and Seizure Based Stimulation (CASBAS). This approach aims at continuously providing high-quality seizures to optimize the outcome. While this dosing strategy was applied in our department, the pulse width was changed for a period of time from BP to UBP. It was hypothesized that the procedure would: (1) maintain seizure quality and clinical outcome under both conditions and would; and (2) compensate the lesser clinical efficacy of UBP by an increase in stimulus intensity. 245 patients received an ECT course according to the dosing strategy described, 162 with brief pulse (BP) and 83 with ultrabrief pulse ECT (UBP). In a retrospective evaluation, seizure quality and clinical outcome (available in a 20% subgroup of patients) did not differ between both groups in most of the examined parameters, while stimulus intensity was found to be significantly higher in the UBP group. As hypothesized, UBP was less efficient than BP in providing comparable ictal quality and clinical outcome. In a first test of concept the dosing strategy CASBAS seemed suitable to continuously adjust the stimulus intensity in ECT and maintain the seizure quality.