The Enemy of Good Is Not Precision

Jorgensen et al1 conducted a valuable assessment of technical and clinical electroconvulsive therapy (ECT) variables using electronic health records from 5 Danish adult psychiatric departments. All departments adhered to national guidelines, utilizing a Thymatron System IV (“2X dose” program), bitemporal electrode placement for initiation, age-based dosing (“age” for bitemporal and “half-age” for unilateral), and dose escalation in response to seizure inadequacy. While their results revealed considerable variability in seizure adequacy and subsequent charge adjustments throughout the ECT course, the use of bitemporal electrode placement, 900 mA current, brief pulse width, and the “2X dose” program likely contributes to the observed 50% to 70% reduction in Hamilton Depression Rating Scale scores, thereby assuring against inadequate dosing. However, these upper-limit dosing parameters do not protect against excessive dosing, a concern compounded by the absence of reliably recorded cognitive data in this investigation. Dr Kellner’s commentary offers valuable, historically informed insights into the variability inherent in real-world ECT practice.2 We concur with several of Dr Kellner’s key assertions: that efforts to mitigate cognitive side effects must not compromise ECT’s unparalleled efficacy; that the variability in standard ECT practice (eg, between seizure threshold and demographic-based dosing) is often clinically trivial for the majority of patients; and that appropriate patient selection remains a critical determinant of ECT outcomes. However, we respectfully diverge from the notion that “perfection is the enemy of the good,” and with the implication that current efforts toward greater technical and physiological rigor reflect misplaced perfectionism. Much of contemporary ECT practice continues to reply on dosing conventions established before the advent of modern neuroimaging, computational modeling, and systematic approaches to individualized dosing. For instance, unilateral dosing with bitemporal contingency often necessitates a trial-and-error approach, potentially leading to weeks of suboptimal dosing and prolongation of the overall ECT series. While often transient and not universally experienced, the cognitive side effects associated with traditional ECT can extend recovery times, obscure antidepressant and functional recovery timelines, and persist as a significant deterrent for both prospective and returning patients. Furthermore, Dr Kellner’s assertion that “electric field (E-field) is just a theory and not measurable in patients” requires clarification. While E-field calculations rely on modeling assumptions such as tissue conductivity and quasi-static approximation,3 E-field is not a theoretical construct. E-fields are indeed measurable in vivo,4 and E-field modeling provides a biophysically grounded framework that links device parameters, electrode configuration, and individual anatomy to brain exposure. Dismissing E-field modeling as “just theory” risks overlooking its growing empirical validation and established utility across neuromodulation modalities.5 It is true that some past efforts to improve ECT’s cognitive profile (eg, through techniques like Focal Electrically Administered Seizure Therapy6 and ultrabrief pulse width7) have regrettably compromised efficacy. However, these outcomes should not be interpreted as evidence that technical refinement is inherently detrimental. Rather, many such efforts were undertaken in the absence of quantitative dose-exposure metrics, neuroimaging-informed targeting, or individualized dosing frameworks, increasing the risk of suboptimal brain engagement. These experiences underscore the need for better models and biomarkers to guide innovation, not a justification for accepting current practice as maximally optimized. Regarding Dr Kellner’s recommendation for “high-quality EEG monitoring,” it is crucial to acknowledge that current practice largely lacks robust quantitative seizure metrics to definitively determine seizure adequacy. Instead, we often rely on qualitative assessments of seizure morphology, which are inherently subjective and heavily dependent on the individual ECT clinician’s experience. More fundamentally, the field lack definitive understanding of which physiological features of the induced seizure, and its downstream neurophysiologic consequences, such as post-ictal suppression and cortical spreading depolarization,8 are causally linked to antidepressant response and cognitive risk. Moreover, we have yet to precisely define an anatomic or network target for optimal electrode placement, continuing to rely on montages developed as early as the 1940s. Emerging work on alternative dosing strategies, including amplitude-determined seizure titrations and E-field informed ECT, shows significant promise,9 even if these approaches are not yet ready for widespread clinical adoption. Nevertheless, they clearly point towards a future where greater precision is achievable. Further dedicated research into individualized electrode placements, including the use of multichannel arrays, and the development of novel waveforms and stimulation patterns (eg, alternating biphasic waveforms and theta-burst stimulation) are critical next steps. Ultimately, the choice facing the field is not between perfectionism and pragmatism, but between opaque tradition and accountable, data-informed practice. ECT’s extraordinary effectiveness is precisely why continued refinement—through next-generation neuroimaging, computational modeling, and device development—is both scientifically justified and ethically necessary.