Sir: I read with interest the article by Jan Wise et al (Psychiatric Bulletin, August 2000, 24, 301). The authors cast doubts about using the Hamilton cuff method for assessing seizure duration and recommended EEG monitoring as a standard procedure need of ECT. EEG seizure monitoring indeed helps to prevent unwarranted restimulation as well as detecting prolonged seizures (Reference Mayur, Gangadhar and JanakiramaiahMayur et al, 1999), however the use of the cuff technique needs to be viewed in terms of its benefit and risk, especially in places where EEG monitoring is not available. Jan Wise et al have not reported the dosage of the muscle relaxants used. For patients who require high dose of succinylcholine, > 1.0 mg/kg, (eg. patients with bone and joint problems who require complete muscle paralysis, or patients who need longer ECT session for stimulus dose titration), seizure could be masked. In addition, the finding that there was no significant difference in seizure duration between cuffed and uncuffed limbs could be limited by a lack of blindness between three observers. All raters were using a similar approach to note the seizure duration at the same time and place.

I have reservation in disregarding the cuff technique and would rather support the College recommendation (Royal College of Psychiatrists, 1995) that cuff duration should be kept to a minimum and the cuff inflation should be released as soon as adequate seizure duration has occurred. Care also needs to be taken for patients with severe osteoporosis, other major orthopaedic problems and sickle cell disease (Reference Weiner, Coffey and KrystalWeiner et al, 1991).