The choice of which type of ECT is best for continuation therapy also is in question. In this single-center study conducted in Berlin between 2004 and 2010, ultrabrief pulse ECT was administered weekly for 4 weeks, biweekly for 8 weeks, and monthly for 3 months, titrated based on the individual seizure threshold established during the first continuation treatment and kept constant thereafter.
In the study, Dr. Bajbouj and his coauthors noted that the results indicated that ultrabrief ECT as a continuation therapy might be less effective than more established forms of ECT with broader pulse widths. “The way we did the continuation ECT therapy is not the way we would do it today,” Dr. Bajbouj said.
So, what of this question of how to factor in possible synergies created when multiple treatments are administered? Dr. Bajbouj pointed to another of his studies, this one done to determine whether the molecular mechanisms of the pretreatments ketamine or lithium used in repetitive transcranial magnetic stimulation affected outcomes (Eur Arch Psychiatry Clin Neurosci. 2012 Feb;262[1]:87-91. doi: 10.1007/s00406-011-0217-3).
Dr. Bajbouj and his colleagues found that pretreatment with ketamine potentiated neuronal cells, while pretreatment with lithium attenuated the cellular response to repetitive magnetic stimulation.
“It’s very oversimplified,” Dr. Bajbouj said. However, a difference in cellular synergies was found, leading Dr. Bajbouj to say that the notion of treatment synergies is “not adequately regarded currently in the field of ECT.”
In the meantime, Dr. Bajbouj laid out a “wish list” for how he’d like to see ECT as well as other brain stimulation techniques become integrated into the mainstream of treatment techniques for depression. Included were the broader use of transcranial magnetic stimulation, more ECT in the depressed elderly and in those with refractory depression, and direct brain stimulation, which he said “might be something for the very severely ill and could prevent relapse.”
It might be a while, though. Despite plenty of data in support of ECT and Dr. Bajbouj’s own data in favor of combining CBT with pharmacotherapy after ECT, the results from an Internet survey showed that, “If you were to ask patients in Germany what they would do if they were depressed, ECT doesn’t even appear.” In the survey, psychotherapy ranked first. “Take antidepressants” ranked between “eat chocolate” and “go on vacation.”
Dr. Bajbouj did not have any relevant disclosures.
On Twitter @whitneymcknight