Electroconvulsive Therapy for Catatonia

To the Editor: We applaud the excellent care described by Marc H. Zisselman, M.D., and Richard L. Jaffe, M.D., (1) in their Clinical Case Conference published in the February 2010 issue of the Journal. Their case presentation and discussion highlight important issues in the recognition and urgent, definitive treatment of catatonia in a young patient. We would like to suggest an alternative ECT treatment procedure when urgent/emergent situations, such as the one described, occur. Since the most effective ECT is indicated, stimulus dosing should be high and consideration should be given to inducing two seizures per ECT session (en bloc ECT) until clinical improvement is apparent (2). Although the authors commented that the initial stimulus setting of 20% of the device maximum was higher than would have been prescribed by the half-age method (3), this was still very conservative. We would recommend liberal stimulus dosing, with the goal of inducing the most powerful and well-generalized seizures possible. The rationale for conservative stimulus dosing in routine ECT is to minimize effects on cognition, a consideration that does not apply to the use of ECT as a life-saving treatment in a seriously catatonic patient. While one cannot argue with the excellent outcome in the case presented in the Journal, we feel it is important for readers to understand that in most similar situations, every effort should be made to maximize the efficacy of the ECT administered in order to ensure the quickest and most robust clinical response. The medical sequelae of prolonged catatonia can be very serious. Early, definitive intervention offers the patient the best chance of full recovery.