High Seizure Threshold? : Case Series From Japan

Out on PubMed, from clinicians in Japan is this paper:

Serial case report of high seizure threshold patients that responded to the lengthening of pulse width in ECT.
Katagai H, Yasui-Furukori N, Kawashima H, Suwa T, Tsushima C, Sato Y, Shimoda K, Tasaki H.Neuropsychopharmacol Rep. 2021 Dec 24. doi: 10.1002/npr2.12224. Online ahead of print. PMID: 34953064
The abstract is copied below:

Electroconvulsive therapy (ECT) has been used as an effective treatment modality for psychiatric disorders. In patients with high seizure thresholds, augmentation strategies are considered such as changing anesthetic agents, hyperventilation, and premedication with theophylline. We tried to switch to "long (1.5 ms)" brief pulse ECT in all six patients from October 2020. The successful induction of effective seizures with "long" brief pulse stimulation in five of six patients who could not be treated adequately with standard ECT. In the current situation in cases in which brief pulse ECT, with the maximum dose did not lead to effective seizures, "long" brief pulse waves may be a promising option.

Keywords: electroconvulsive therapy; seizure thresholds; thymatron; “long” brief waves.




This case series leaves us with more questions than answers. First of all, the authors provide no convincing evidence that these patients actually had high seizure thresholds (STs). Perhaps they had short seizures because they were being stimulated at way OVER their ST. Please remember the compelling data from the Harvard group that increasing charge leads to shorter seizures. Whether the strategy proposed here, of increasing pulse width, does, in fact lead to longer (and presumably more effective) seizures in some patients remains open to debate. Much has been written about optimal stimulus parameters in ECT, including the advantages of long duration, low frequency packages. Don't forget good hyperventilation...
Scholars of the ECT stimulus should read this short paper, and are encouraged to comment, please.

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