Optimizing the technique of ECT can minimize cognitive side effects. These optimizing measures for ECT technique are:
Use brief pulse stimulus (0.5 to 2 milliseconds)instead of sine wave stimulus. This has a positive effect on cognitive side effects. It is not yet clear if ultrabrief pulse waveform (pulse width of less than 0.5 milliseconds) will produce even fewer cognitive side effects without sacrificing efficacy.
Right Unilateral Electrode placement when performed right has the best benefit/risk ratio concerning cognitive side effects. Performed right means using brief pulse stimulus or better ultrabrief stimulus with a dosage of 6 times seizure threshold. Bilateral brief pulse ECT with a dosage of 2.5 times threshold has comparable efficacy at the risk of more severe cognitive side effects. Bifrontal electrode placement may represent a better benefit/risk ratio compared to bilateral ECT. Statements comparing bifrontal and right unilateral ECT is premature because of lack of sufficient data about comparison of side effects and efficacy
Dosing by titration schedule is critical to reducing adverse cognitive side effects. Adverse cognitive side effects of ECT are attributable to the dose above seizure threshold not to absolute electrical dose. Aged based dosing methods cannot be advised because of only modest association of age with seizure threshold.
The frequency of twice weekly treatment schedules result in fewer cognitive side effects than higher frequency schedules. Increasing frequency increases the risk of side effects.
The number of treatments predicts the extent of cognitive side effects in bilateral ECT not in unilateral ECT. If bilateral ECT is administered, minimizing the number of treatments may offer some protection against the development of persistent cognitive deficits.
Prudic, J. (2008). Strategies to minimize cognitive side effects with ECT: aspects of ECT technique.. Journal of ECT, 24(1), 46-51.