Abstract

Over a course of electroconvulsive therapy (ECT) there is frequently a progressive rise in seizure threshold and an associated reduction in the duration of the electrically induced seizure (Sackeim et al. 1986). The recognition of brief ECT-induced seizures is of clinical importance because they may not be as effective as those of moderte duration and because they may herald the occurrence of missed seizures at subsequent ECT treatments (Ottosson 1960; Milstein and Small 1984; Sackeim et al. 1986). Techniques to maintain adequate seizure duration over a course of ECT are therefore of considerable clinical relevance. Because of the paucity of applicable clinical data, the definition of “adequate seizure duration” remains unclear. The proposal of a rather arbitrary cutoff of 25 set (Weiner 1979; Fink and Johnson 1982) has received wide clinical acceptance. The typical clinical approach to maintaining seizures of 25 set or greater during a course of ECT is to increase the intensity of the ECT stimulus when seizure duration becomes too brief (Fink 1979; Weiner 1979). A higher stimulus energy, however, may be associated with greater encephalopathic side effects (confusion, amnesia, EEG slowing) and obviously cannot be accomplished when the ECT device is already at maximal settings (Fink et al. 1958; Ottosson 1960). Recently, we (Hinkle et al. 1987) described six depressed inpatients receiving ECT whose seizure durations were declining despite maximal settings on three different commercially available ECT instruments. In each case, we found that the use of caffeine administered intravenously prior to the delivery of the ECT stimulus resulted in a marked lengthening of the seizure duration (mean increase of 107%), and all patients subsequently experienced a clinical remission of their depression (Hinkle et al. 1987). These findings raised the possibility that caffeine pretreatment could be used routinely to limit increases in electrical energy delivered during a course of ECT. We now describe a new series of depressed patients receiving ECT in whom pretreatment with caffeine reversed a pattern of declining seizure duration and reduced the need for frequent increases in ECT stimulus over the course of therapy.

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