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Year : 2020  |  Volume : 42  |  Issue : 3  |  Page : 207-218  

Frequency and duration of course of ECT sessions: An appraisal of recent evidence

1 Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India
2 Consultant Psychiatrist, Bradgate Mental Health Unit, Leicester, England, UK

Date of Submission06-Oct-2019
Date of Decision14-Dec-2019
Date of Acceptance03-Apr-2020
Date of Web Publication25-Apr-2020

Correspondence Address:
Dr. Jagadisha Thirthalli
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru - 560 029, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPSYM.IJPSYM_410_19

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Aims and Method: This paper aims to review the recent literature regarding factors influencing the frequency and number of sessions during a course of electroconvulsive therapy (ECT) for different psychiatric disorders. We systematically reviewed English-language papers of clinical trials of ECT published since the year 2000 in terms of frequency and number of sessions of ECT. Results: None of the 30 studies meeting our inclusion criteria were specifically designed to study frequency or number of sessions of ECT. A preliminary inference may be drawn regarding the number of sessions from the information available in these papers. For depression, patients receiving brief-pulse ECT needed fewer sessions than those receiving ultra-brief ECT when these were delivered at 8-times the threshold with unilateral electrode placement or at 2.5-times the threshold with bilateral placement. For schizophrenia, those receiving bifrontal ECT and ECT at 4-times the threshold-level stimulus needed fewer sessions than those receiving bitemporal ECT and 2-times the threshold-level stimulus, respectively. There were no clinical trials of the frequency of ECT sessions.Clinical Implications: A s there is a dearth of studies specifically examining frequency and number of ECT sessions, broad recommendations from professional bodies should continue to guide practice.

Keywords: Electroconvulsive therapy, frequency, schedule

How to cite this article:
Thirthalli J, Naik SS, Kunigiri G. Frequency and duration of course of ECT sessions: An appraisal of recent evidence. Indian J Psychol Med 2020;42:207-18

How to cite this URL:
Thirthalli J, Naik SS, Kunigiri G. Frequency and duration of course of ECT sessions: An appraisal of recent evidence. Indian J Psychol Med [serial online] 2020 [cited 2020 May 24];42:207-18. Available from:

Electroconvulsive therapy (ECT) continues to be an important treatment modality in psychiatry even after about eight decades of its first use. For well-defined indications, ECT is highly effective. An important concern regarding ECT is the cognitive adverse effects associated with it. A substantial body of research has concentrated on reducing the cognitive adverse effects while not compromising on its therapeutic usefulness. Researchers have explored variations in electrical aspects of the stimulus, electrode placement (EP), co-prescribed medications, anesthetic agents, etc., to achieve this. Frequency and number of sessions during a course of ECT are also important considerations in this context.

In this paper, we review the literature related to frequency and number of sessions during a course of ECT. Three influential sources reviewed the knowledge about these aspects in the early 2000s.[1],[2],[3] We first provide the gist from these sources; then, we follow this up with a systematic review of the research published since the turn of this millennium.

The frequency of ECT sessions has varied across regions and settings. In the US and Israel, thrice-weekly ECT is a common practice,[4],[5] while in the UK, twice-weekly sessions are commonplace.[6] Some authors[7] have argued for 4-5 sessions of ECT per week to enhance the speed of recovery. Based on the extended research in this field, the Taskforce Report of the American Psychiatric Association (APA) on ECT[1] recommends twice or thrice weekly ECT sessions, with a caution that more frequent sessions could result in higher cognitive deficits and a suggestion that frequency of sessions should be reduced if cognitive effects are of serious concern. The Royal College of Psychiatrists' (RCP) ECT Handbook[2] recommends the use of twice weekly ECTs for bilateral ECT; it suggests that the use of thrice-weekly bilateral ECT should be reserved only for life-threatening illnesses and for as long as the threat is high. It suggests that unilateral ECT be administered twice weekly. In his book on ECT, Abrams[3] recommended the use of twice weekly ECT with bilateral ECTs; he also observed that biweekly ECT might need fewer sessions to achieve comparable efficacy as thrice weekly ECT.

The number of sessions in a course of ECT is largely determined by individual patient's response. Generally, the ECT course is stopped as soon as remission from symptoms is achieved or if the initial improvement remains unchanged for two additional sessions.[1] Research examining the optimum number of ECTs for different indications is sparse. APA task force report suggests 6–12 sessions for depression, with a caveat that given patients may need more or less than these number of sessions. The number could be higher for patients in whom ECT protocol was changed and those with schizophrenia. Based on the observation by Segman et al.,[8] the RCP handbook suggested that bilateral ECTs for depression may be stopped if there is no improvement at all during the first six treatments; if there is some improvement, then a substantial minority of patients would respond and, hence, it may be worthwhile continuing ECTs for up to 12 sessions. Abrams'[3] recommendations regarding bilateral ECT for depression were largely similar to the ones by the RCP handbook.

We aimed to review the recent literature about the number and frequency of ECT sessions. We examined the literature for factors that may influence the number and frequency of ECT sessions for different psychiatric conditions and synthesized the findings. These factors include anesthetic agents used during ECT, electrical aspects of ECT, and ECT EPs.

   Method Top

For this review, we followed the relevant sections of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched the PubMed database with the following search term: Electroconvulsive therapy [mesh]. We used “English,” “clinical trials,” “human,” “articles with abstracts,” and “publication dates between January 1st, 2000 and March 31st, 2019” as filters. A single author, SSN reviewed all the abstracts and selected papers that met the following inclusion criteria: the paper describes a clinical trial or posthoc analysis of data from clinical trials, and there is mention of the number of ECT sessions in the comparative groups or there is a comparison of different treatment schedules in terms of the number of ECT sessions. We excluded studies for reasons listed in [Figure 1]. SSN reviewed the full texts of all the selected studies and excluded further studies if they had both fixed number of ECT treatment sessions and fixed frequency of ECT treatments, no information was provided on both treatment schedules and total number of ECT treatment sessions, and if they were anecdotal case series/reports, articles on the same study cohort and reported the same observations,[9],[10] or a study that was included in our previous review.[11] [Figure 1] provides the details of this process. This systematic review protocol was not registered in any online database.
Figure 1: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart for the selection of studies

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Each full-text paper was reviewed thoroughly, and the following details were extracted: aim of the study, sampling details, sample size, diagnosis, indication for ECT, comparison groups, details of anesthetic agents, details of electrical stimulus, EP, frequency of sessions, the total number of ECTs, and the reasons for terminating ECTs. In this paper, we focus on the findings on the frequency and number of ECT sessions. In some studies, there were major changes in ECT protocols (e.g. switching from unilateral to bilateral ECT). In such cases, we took into consideration only the details of the ECT sessions before the change.

We assessed the methodological quality of the studies using the Jadad score[12] if they were clinical trials. It is a system of evaluating the quality of clinical trials on the basis of randomization, blinding, and method of addressing dropouts. The score ranges from zero to five, a higher score indicating better quality.

   Results of the Systematic Review Top

[Table 1] shows the details of the studies reviewed. We classified the studies as those examining the effects of anesthetic agents, EP, stimulus parameters such as pulse width and stimulus intensity, concurrent use of anticonvulsants, and clinical characteristics. We have synthesized the results for each of these influencing factors.
Table 1: Details of clinical trials included in the systematic review

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To understand the importance of the number of sessions, it is vital to know the reason for the termination of ECT. In 8 (26.7%) of the 30 studies, there was no mention of the policy to determine the number of sessions. In all but one[13] of the rest of the studies, the decision was left to the treating clinicians. Nine (30%) of the 30 studies provided the details of patients in whom ECT was terminated because of adverse effects;[13],[14],[15],[16],[17],[18],[19],[20],[21] in all these studies, these numbers were too small for meaningful statistical analysis. However, none of the studies provided information about the proportion of patients in whom ECT was terminated due to a lack of clinical improvement.

Seven studies[14],[15],[16],[22],[23],[24],[25] examined the influence of anesthetic agents. All but two studies included patients with depression. Canbek et al.[24] included patients with diagnoses of mania, psychosis, catatonia, or depression. Tripathi et al.[23] included patients with depression, schizophrenia, or mania. In none of these studies, there was a significant difference between the compared groups in terms of the number of ECTs received [Table 1].

Nine studies[10],[13],[17],[18],[26],[27],[28],[29],[30] investigated the effects of EP. Six of these compared right unilateral (RUL) EP with another EP. The rest three compared different bilateral EP with one another. Seven studies included patients with depression; Hiremani et al.[27] and Phutane et al.[28] examined patients with mania and schizophrenia, respectively. Phutane et al.[28] found that schizophrenia patients treated with bifrontal ECTs received one less session than those treated with bitemporal ECTs. Other studies found no difference in the number of ECTs between the compared groups.

Two studies[19],[31] compared ECT with brief (BP) and ultra-brief (UBP) pulse widths in patients with depression. Patients in the BP ECT group received significantly less number of ECTs [Mean (SD) = 7.1 (2.6)] than those in the UBP group [9.2 (2.3)] by two ECT treatment sessions when both BP and UBP ECTs were administered using unilateral EP and stimulus at eight times the initial seizure threshold (ST).[19] However, BP-ECTs at five times ST and UBP-ECTs using unilateral EP at eight times ST were comparable.[31] One study[32] researched the effects of both EP and pulse width in patients with medication-resistant depression. Those in the UBP bilateral EP group had a significantly higher number of ECTs [Mean (SD) = 8.9 (2.5)] as well as a larger proportion of non-responders to ECT when compared to the three groups, UBP-RUL [8.7 (2.4)], BP bilateral [6.2 (2.4)], and BP-RUL [8.5 (2.5)].

Three studies[33],[34],[35] examined the effects of electrical stimulus intensity. Chanpattana et al.,[33] Mc Call et al.,[34] and Mohan et al.[35] included patients with schizophrenia, depression, and mania, respectively. Chanpattana et al. study showed that patients of treatment-resistant schizophrenia receiving high stimulus dosage bilateral-ECT [2ST = 12.5 (3.8); 4ST = 9.2 (1.5)] needed significantly less number of ECTs than those receiving low stimulus dose bilateral ECT [ST = 18.6 (5)]. The rest two did not find a significant difference in the number of ECTs.

Three studies[20],[21],[36] compared the clinical efficacy of various dose strengths of electrical stimulus using RUL EP with that of standard BL in patients with depression. None of them found a significant difference among compared groups with respect to the number of ECT treatments.

Two studies[37],[38] explored the effects of concurrent use of anticonvulsants. Both were conducted in patients with bipolar affective disorder. Neither found any significant influence of continuing anticonvulsants in terms of the number of ECT sessions.

Two studies[39],[40] explored the putative predictors of early response to ECT in depression. Expectedly, those with early-course remission needed significantly less number of ECTs than late or non-responders. Older age,[39],[40] use of BP stimulus waveforms,[31] and the presence of psychotic symptoms[40] were associated with early course remission.

Sienaert et al.[41] studied the speed of response to ECT in pharmacotherapy resistant depressive patients, comparing the polarity of their mood disorder. Patients with bipolar depression needed significantly less number of ECTs than those with unipolar depression by about three ECT sessions.

In two-thirds of the studies, the mean number of ECTs was between 6 and 10. In 4 (14.3%) studies, it was less than six and in 7 (25%) studies, it was more than 10. Patients (treatment-resistant schizophrenia) in the study by Chanpattana et al.[33] had received a substantially higher number of ECTs than the patients in other studies, but this number includes sessions of both acute course as well as the “stabilization” phase. Those with early and late remission in the study by Spaans et al.[40] received less than six and more than 10 ECT sessions, respectively, on an average. In Rhebergen et al.[39] study, patients with non-remission received up to 20 ECTs.

Of the 30 studies, 27 were clinical trials, and three studies were posthoc analyses of clinical trials. The quality of most studies was good. Eighteen (66.7%) studies had Jadad score[12] of 5. Two (7.4%), 4 (14.8%), 2 (7.4%), and 1 (3.7%) had Jadad score of 4, 3, 2, and 1, respectively.

We did not find any original research study examining the effect of the frequency of ECT sessions, published during the review period. Gangadhar and Thirthalli published a narrative review of studies of the frequency of ECT sessions in 2010.[42] They observed that for acute management of depression with bilateral ECT, the antidepressant effect was comparable between twice-weekly and thrice-weekly schedules. While a tendency of those receiving thrice-weekly ECT experiencing faster improvement was noted, it was associated with more cognitive deficits as well. Overall, the twice-weekly schedule had the best balance between efficacy and cognitive outcomes. Samples of most studies did not reflect patients who would receive ECT in clinical practice—for instance, in several studies, patients were either off antidepressant medications for a few weeks or were treatment-naïve at the time of the trials. Regarding acute management of schizophrenia and mania as well as continuation/maintenance ECT for any indication, the authors noted a serious dearth of quality studies to guide practice.

   Discussion Top

In this systematic review, we did not find any original research study examining the issue of frequency of ECT sessions. We found 30 studies that examined the number of ECT sessions. However, in none of them, the primary aim was to examine the number of ECTs—it was one of the secondary objectives in all these studies.

Studies researched a wide array of questions: the influence of anesthetic agents, EP, stimulus parameters such as pulse width and stimulus intensity, concurrent use of anticonvulsants, and clinical characteristics. A few studies reported significant results: Patients with schizophrenia receiving ECT with bifrontal EP had about one ECT session less than those who received ECT with bitemporal EP.[28] Patients with depression receiving brief-pulse ECT needed about two sessions less than those receiving ultra-brief ECT when both were administered with unilateral EP using stimulus at eight times the seizure-threshold.[19] When patients were treated for depression with bilateral ECT, those receiving brief pulse ECT needed about two sessions less than those treated with ultra-brief pulse ECT.[32] Treatment-resistant schizophrenia patients receiving bilateral ECT at four times their seizure-threshold needed seven and nine ECT sessions less than those receiving two times and barely above their threshold levels, respectively.[33] In depression, rapidly remitting patients received 10 and 13 ECTs less than slowly remitting and non-remitting patients, respectively.[39],[40] Patients with bipolar depression received three ECT sessions less than those with unipolar depression.[41] In all these studies, as expected, the results for the number of ECTs reflected the findings on the efficacy of ECT measured using alternative methods. Most studies did not find a significant difference between the compared groups in terms of the number of ECT sessions. Interestingly, in three studies,[10],[27],[34] though there was a significant difference between comparison arms in terms of clinical outcomes, it did not reflect in the number of ECT sessions.

In all but one of the studies, the policy of when the ECT course is terminated was either not mentioned or was left to the clinicians. Clinicians may decide to terminate ECT sessions based on several factors: achievement of therapeutic target (i.e., some threshold of improvement), plateauing of response after an initial improvement, development of significant adverse effects (particularly cognitive ones), or as per the patients' choice. Unfortunately, the proportion of patients in whom the ECT course was terminated for different reasons is not mentioned in these papers. Hence, the interpretation of both the positive and the negative findings becomes hard. In most studies, the mean number of ECT sessions was between 6 and 10; in the absence of data on reasons for stopping ECT between responders and non-responders, it is difficult to interpret this finding as well.

It is apparent that when rapid improvement is clinically warranted, thrice-weekly ECT may be preferred. Given that both twice-weekly and thrice-weekly ECTs are equally efficacious, what are the cost implications when clinical situations do not warrant rapid improvement? Costs depend on the number of ECT sessions and duration of inpatient stay. In the UK, for instance, six treatment sessions of ECT cost about £ 2475;[43] inpatient costs are estimated as about £ 171 per day. Unfortunately, the current literature does not provide useful insights into this important aspect. Of the four studies that compared twice- vs. thrice-weekly ECTs in depression, three used bilateral ECT, which is recommended to be used only when there is clinical urgency. The only study that used unilateral ECT[44] did not specify the dose of the electrical stimulus, and hence, it is uncertain if it reflects contemporary ECT practice. Among the ones which studied bilateral ECT, one study[45] had fixed the number of ECTs, and hence it is not possible to assess the cost advantage; two other studies[5],[46] found that patients receiving thrice-weekly ECT received more sessions than those receiving twice-weekly ECT. However, the criteria used for termination of ECT in these studies do not reflect clinical practice, and hence, the translational value of this observation is doubtful.

ECT is frequently used in situ ations where rapid improvement is required, e.g. acutely suicidal/catatonic/aggressive patients. In fact, APA taskforce observes, “primary use of ECT should be considered when a rapid or a higher probability of response is needed, such as when patients are severely medically ill or at risk to harm themselves or others.” ECT is also frequently used when medical conditions (including pregnancy) either preclude the use of a full dose of antidepressants or warrant urgent relief of symptoms. There are two important reasons as to why literature from clinical trials may not be useful while making clinical decisions: (a) Most ECT literature comes from research conducted on patients who do not belong to the above categories. (b) When clinicians use ECT for such indications, then the number of ECTs and the decision to terminate a course may depend on a number of factors including achieving a specific clinical target (for example, reduction of suicidal risk, resolution of catatonic symptoms, patient starting to eat, etc.) and not necessarily because the patient had achieved response, remission, or plateauing of response.

Barring a few studies,[24],[34],[37],[40] the SD for the number of sessions is more than 2. It is reasonable to assume that the difference in the mean number of ECT sessions between the compared groups should be at least one for the finding to be clinically meaningful. For studies to show a clinically meaningful difference of one session between the compared groups with a conservative estimate of SD of 2 (i.e., a standardized mean difference of 0.5), the sample size in each of the compared groups should be about 60 in each group with 80% power and with type-1 error rate of 0.05.[47] It may be noted that most studies included much smaller samples and hence were underpowered with regard to the number of ECT sessions.

As described in the introduction section, professional bodies[1],[2] and authors of textbooks on ECT[3] have made certain recommendations regarding the frequency of ECT sessions in the early 2000s. This review of the past two decades of research adds little to these recommendations. Regarding the recommendations about the number of ECTs, this review suggests that those receiving ultra-brief pulse ECT for depression and those receiving threshold-level stimulus with bilateral ECT for schizophrenia would require a greater number of ECT sessions, albeit with the caveats discussed above.

   Conclusions Top

Frequency and number of sessions are important clinical aspects of ECT practice. In this paper, we attempted an appraisal of research pertaining to these aspects. There is a serious dearth of contemporary literature specifically examining these questions. The information available from studies with different aims provides important insights, which need to be pursued in future research. Until then, the broad recommendations suggested by professional bodies[1],[2],[48] should continue to guide ECT practitioners.

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Conflicts of interest

There are no conflicts of interest.

   References Top

American Psychiatric Association, Weiner RD, editors. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging: A Task Force Report of the American Psychiatric Association. 2nd ed. Washington, D.C: American Psychiatric Association; 2001. p. 355.  Back to cited text no. 1
Royal College of Psychiatrists (GB), Scott AIF. The ECT handbook. London: Gaskell; 2005.  Back to cited text no. 2
Abrams R. Electroconvulsive Therapy. 4th ed. Oxford; New York: Oxford University Press; 2002. p. 328.  Back to cited text no. 3
Sackeim HA. ECT: Twice or Thrice a Week? Convuls Ther 1989;5:362-4.  Back to cited text no. 4
Lerer B, Shapira B, Calev A, Tubi N, Drexler H, Kindler S, et al. Antidepressant and cognitive effects of twice- versus three-times-weekly ECT. Am J Psychiatry 1995;152:564-70.  Back to cited text no. 5
Pippard J, Ellam L. Electroconvulsion treatment in Great Britain 1980. Lancet 1981;21160-1.  Back to cited text no. 6
Strömgren LS. Therapeutic results in brief-interval unilateral ECT. Acta Psychiatr Scand 1975;52:246-55.  Back to cited text no. 7
Segman RH, Gorfine M, Lerer B, Shapira B. Onset and time course of antidepressant action: Psychopharmacological implications of a controlled trial of electroconvulsive therapy. Psychopharmacology 1995;119:440-8.  Back to cited text no. 8
Sienaert PA, Vansteelandt K, Demyttenaere K, Peuskens J. Predictors of patient satisfaction after ultrabrief bifrontal and unilateral electroconvulsive therapies for major depression. J ECT 2010;26:55-9.  Back to cited text no. 9
Sienaert P, Vansteelandt K, Demyttenaere K, Peuskens J. Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy. J Affect Disord 2009;116:106-12.  Back to cited text no. 10
Shapira B, Tubi N, Lerer B. Balancing speed of response to ECT in major depression and adverse cognitive effects: Role of treatment schedule. J ECT 2000;16:97-109.  Back to cited text no. 11
Halpern SH, Douglas MJ, editors. Appendix: Jadad scale for reporting randomized controlled trials. In: Evidence-based Obstetric Anesthesia [Internet]. Oxford, UK: Blackwell Publishing Ltd; 2005. p. 237-8. Available from: [Last cited on 2019 May 07].  Back to cited text no. 12
Stoppe A, Louz?? M, Rosa M, Gil G, Rigonatti S. Fixed high-dose electroconvulsive therapy in the elderly with depression: A double-blind, randomized comparison of efficacy and tolerability between unilateral and bilateral electrode placement. J ECT 2006;22:92-9.  Back to cited text no. 13
Bauer J, Hageman I, Dam H, Báez A, Bolwig T, Roed J, et al. Comparison of propofol and thiopental as anesthetic agents for electroconvulsive therapy: A randomized, blinded comparison of seizure duration, stimulus charge, clinical effect, and cognitive side effects. J ECT 2009;25:85-90.  Back to cited text no. 14
Fernie G, Currie J, Perrin JS, Stewart CA, Anderson V, Bennett DM, et al. Ketamine as the anaesthetic for electroconvulsive therapy: The KANECT randomised controlled trial. Br J Psychiatry 2017;210:422-8.  Back to cited text no. 15
Carspecken CW, Borisovskaya A, Lan S-T, Heller K, Buchholz J, Ruskin D, et al. Ketamine anesthesia does not improve depression scores in electroconvulsive therapy: A randomized clinical trial. J Neurosurg Anesthesiol 2018;34:305-13.  Back to cited text no. 16
Kellner CH, Knapp R, Husain MM, Rasmussen K, Sampson S, Cullum M, et al. Bifrontal, bitemporal and right unilateral electrode placement in ECT: Randomised trial. Br J Psychiatry 2010;196:226-34.  Back to cited text no. 17
Semkovska M, Landau S, Dunne R, Kolshus E, Kavanagh A, Jelovac A, et al. Bitemporal versus high-dose unilateral twice-weekly electroconvulsive therapy for depression (EFFECT-Dep): A pragmatic, randomized, non-inferiority trial. Am J Psychiatry 2016;173:408-17.  Back to cited text no. 18
Spaans H-P, Verwijk E, Comijs HC, Kok RM, Sienaert P, Bouckaert F, et al. Efficacy and cognitive side effects after brief pulse and ultrabrief pulse right unilateral electroconvulsive therapy for major depression: A randomized, double-blind, controlled study. J Clin Psychiatry 2013;74:e1029-36.  Back to cited text no. 19
Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000;57:425-34.  Back to cited text no. 20
Heikman P, Tuunainen A. Right unilateral and bifrontal electroconvulsive therapy in the treatment of depression: A preliminary study. J ECT 2002;18:26-30.  Back to cited text no. 21
Ingram A, Schweitzer I, Ng CH, Saling MM, Savage G. A comparison of propofol and thiopentone use in electroconvulsive therapy: Cognitive and efficacy effects. J ECT 2007;23:158-62.  Back to cited text no. 22
Tripathi A, Winek NC, Goel K, D'Agati D, Gallegos J, Jayaram G, et al. Electroconvulsive therapy pre-treatment with low dose propofol: Comparison with unmodified treatment. J Psychiatr Res 2014;53:173-9.  Back to cited text no. 23
Canbek O, Ipekcoglu D, Menges OO, Atagun MI, Karamustafaloglu N, Cetinkaya OZ, et al. Comparison of propofol, etomidate, and thiopental in anesthesia for electroconvulsive therapy: A randomized, double-blind clinical trial. J ECT 2015;31:91-7.  Back to cited text no. 24
Loo CK, Katalinic N, Garfield JBB, Sainsbury K, Hadzi-Pavlovic D, Mac-Pherson R. Neuropsychological and mood effects of ketamine in electroconvulsive therapy: A randomised controlled trial. J Affect Disord 2012;142:233-40.  Back to cited text no. 25
Bailine SH, Rifkin A, Kayne E, Selzer JA, Vital-Herne J, Blieka M, et al. Comparison of bifrontal and bitemporal ECT for major depression. Am J Psychiatry 2000;157:121-3.  Back to cited text no. 26
Hiremani RM, Thirthalli J, Tharayil BS, Gangadhar BN. Double-blind randomized controlled study comparing short-term efficacy of bifrontal and bitemporal electroconvulsive therapy in acute mania. Bipolar Disord 2008;10:701-7.  Back to cited text no. 27
Phutane VH, Thirthalli J, Muralidharan K, Naveen Kumar C, Keshav Kumar J, Gangadhar BN. Double-blind randomized controlled study showing symptomatic and cognitive superiority of bifrontal over bitemporal electrode placement during electroconvulsive therapy for schizophrenia. Brain Stimul 2013;6:210-7.  Back to cited text no. 28
Bjølseth TM, Engedal K, Benth JŠ, Dybedal GS, Gaarden TL, Tanum L. Clinical efficacy of formula-based bifrontal versus right unilateral electroconvulsive therapy (ECT) in the treatment of major depression among elderly patients: A pragmatic, randomized, assessor-blinded, controlled trial. J Affect Disord 2015;175:8-17.  Back to cited text no. 29
Dybedal GS, Bjølseth TM, Benth JŠ, Tanum L. Cognitive effects of bifrontal versus right unilateral electroconvulsive therapy in the treatment of major depression in elderly patients: A randomized, controlled trial. J ECT 2016;32:151-8.  Back to cited text no. 30
Loo CK, Katalinic N, Smith DJ, Ingram A, Dowling N, Martin D, et al. A randomized controlled trial of brief and ultrabrief pulse right unilateral electroconvulsive therapy. Int J Neuropsychopharmacol [Internet] 2015;18. Available from:  Back to cited text no. 31
Sackeim HA, Prudic J, Nobler MS, Fitzsimons L, Lisanby SH, Payne N, et al. Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimul 2008;1:71-83.  Back to cited text no. 32
Chanpattana W, Chakrabhand MLS, Buppanharun W, Sackeim HA. Effects of stimulus intensity on the efficacy of bilateral ECT in schizophrenia: A preliminary study. Biol Psychiatry 2000;48:222-8.  Back to cited text no. 33
McCall WV, Reboussin DM, Weiner RD, Sackeim HA. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: Acute antidepressant and cognitive effects. Arch Gen Psychiatry 2000;57:438-44.  Back to cited text no. 34
Mohan TS, Tharyan P, Alexander J, Raveendran NS. Effects of stimulus intensity on the efficacy and safety of twice-weekly, bilateral electroconvulsive therapy (ECT) combined with antipsychotics in acute mania: A randomised controlled trial. Bipolar Disord 2009;11:126-34.  Back to cited text no. 35
Tew JD, Mulsant BH, Haskett RF, Dolata D, Hixson L, Mann JJ. A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments. J Clin Psychiatry 2002;63:1102-5.  Back to cited text no. 36
Jahangard L, Haghighi M, Bigdelou G, Bajoghli H, Brand S. Comparing efficacy of ECT with and without concurrent sodium valproate therapy in manic patients. J ECT 2012;28:118-23.  Back to cited text no. 37
Rakesh G, Thirthalli J, Kumar CN, Muralidharan K, Phutane VH, Gangadhar BN. Concomitant anticonvulsants with bitemporal electroconvulsive therapy: A randomized controlled trial with clinical and neurobiological application. J ECT 2017;33:16-21.  Back to cited text no. 38
Rhebergen D, Huisman A, Bouckaert F, Kho K, Kok R, Sienaert P, et al. Older age is associated with rapid remission of depression after electroconvulsive therapy: A latent class growth analysis. Am J Geriatr Psychiatry 2015;23:274-82.  Back to cited text no. 39
Spaans H-P, Verwijk E, Stek ML, Kho KH, Bouckaert F, Kok RM, et al. Early complete remitters after electroconvulsive therapy: Profile and prognosis. J ECT 2016;32:82-7.  Back to cited text no. 40
Sienaert P, Vansteelandt K, Demyttenaere K, Peuskens J. Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: Differences in speed of response. Bipolar Disord 2009;11:418-24.  Back to cited text no. 41
Gangadhar BN, Thirthalli J. Frequency of electroconvulsive therapy sessions in a course. J ECT 2010;26:181-5.  Back to cited text no. 42
4 Evidence and interpretation | Guidance on the use of electroconvulsive therapy | Guidance | NICE [Internet]. Available from: [Last cited on 2019 May 26].  Back to cited text no. 43
McAllister DA, Perri MG, Jordan RC, Rauscher FP, Sattin A. Effects of ECT given two vs. three times weekly. Psychiatry Res 1987;21:63-9.  Back to cited text no. 44
Shapira B, Tubi N, Drexler H, Lidsky D, Calev A, Lerer B. Cost and benefit in the choice of ECT schedule: Twice versus three times weekly ECT. Br J Psychiatry 1998;172:44-8.  Back to cited text no. 45
Gangadhar BN, Janakiramaiah N, Subbakrishna DK, Praveen J, Reddy AK. Twice versus thrice weekly ECT in melancholia: A double-blind prospective comparison. J Affect Disord 1993;27:273-8.  Back to cited text no. 46
Norman G, Monteiro S, Salama S. Sample size calculations: Should the emperor's clothes be off the peg or made to measure? BMJ 2012;345:e5278.  Back to cited text no. 47
2 Clinical need and practice | Guidance on the use of electroconvulsive therapy | Guidance | NICE [Internet]. Available from: [Last cited on 2019 May 26].  Back to cited text no. 48


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