How many Electroconvulsive Therapy (ECT) sessions indicate a lack of response to treatment?

Number of ECT Treatments Before Considering Treatment Failure

A standard course of ECT typically consists of 10-12 treatments, with an evaluation of response after 5-6 treatments to determine whether to continue the course. 1

Initial Response Assessment

The decision to continue or discontinue ECT should be based on a careful clinical evaluation of treatment response. Here's how to approach this assessment:

• Evaluate response after the first 5-6 ECT treatments
• Look for initial signs of improvement, which are often observed at this point
• Assess each target symptom individually and overall functioning

Decision-Making Algorithm

If improvement is observed after 5-6 treatments:

• Continue the course to complete 10-12 total treatments
• Monitor for continued improvement
• Document specific symptom changes

If no acceptable response after 5-6 treatments:

• Carefully evaluate each target symptom
• Assess overall functioning
• Consider the following options:
  • Continue ECT (some patients may display improvement later in the course)
  • Modify treatment parameters (e.g., change from unilateral to bilateral electrode placement)
  • Reassess diagnosis and treatment plan

Important Considerations

1. Treatment frequency matters: Most centers in the US administer ECT three times weekly, though twice-weekly administration may be appropriate in some cases, especially if cognitive side effects are significant 1

2. Late responders exist: Some patients may show improvement later in the treatment course, so premature discontinuation should be avoided 1

3. Electrode placement can be adjusted: If response is inadequate with unilateral treatment, changing to bilateral placement may improve outcomes 1

4. Avoid both overtreatment and undertreatment: The decision to continue or discontinue ECT requires careful clinical judgment 1

Special Populations

For adolescents, the same principles apply, with careful monitoring for:

• Prolonged seizures (which may be more common in younger patients)
• Cognitive side effects
• Overall treatment response

Common Pitfalls to Avoid

• Discontinuing too early: Some patients respond later in the treatment course
• Continuing ineffective treatment too long: If no response after 10-12 treatments, consider alternative approaches
• Failing to modify treatment parameters: Consider changing from unilateral to bilateral placement if response is inadequate
• Inadequate monitoring: Careful assessment of target symptoms is essential

Remember that while 10-12 treatments is standard, clinical response should guide the ultimate decision about when to consider ECT a treatment failure. Care must be taken to balance the potential benefits of continued treatment against the risks of cognitive side effects and other adverse outcomes.