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Letters to the Editor
June 2001

Use of Suprathreshold Electroconvulsive Therapy

Arch Gen Psychiatry. 2001;58(6):607. doi:10.1001/archpsyc.58.6.607

The 2 special articles in the May 2000 issue of the ARCHIVES regarding suprathreshold electroconvulsive therapy (ECT)%1,2 raise several concerns. First, because no standard ECT machine now available to practicing clinicians (as opposed to researchers) can deliver the energy needed for suprathreshold treatment of most patients, the relative efficacy of unilateral suprathreshold ECT vs bilateral ECT is moot. Second, because these studies did not include the most severely ill depressed patients, we cannot know the generalizability of these studies. Furthermore, because ECT compared with medications is most cost-effective for treatment of the severely depressed, and because the typical practice in treating patients with mild to moderate depression is with medications rather than ECT, the patients in these 2 studies who will benefit from suprathreshold unilateral ECT will not get it. Lastly, I fear the "take-home message" to most clinicians implied by the commentary%3 accompanying the articles will be this: unilateral ECT is now proven equal to bilateral ECT and with fewer cognitive problems; therefore, it is better. Clinicians will use unilateral ECT at the highest energy permitted by their machine for their most severely ill depressed patients, and no one will know if that process will benefit anyone.

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