From the Editor
He began to respond to ECT and felt less depressed than he had in many years. But as the treatments continued, my patient noticed gaps in his memory including family vacations when his children were young. “Those memories are precious.” He stopped ECT and, soon after, was deeply depressed again.
Smaller studies suggest that Magnetic Seizure Therapy (MST) – where alternating magnetic fields induce seizures – offers relief to patients without the cognitive problems of ECT. In a new study published by The Lancet Psychiatry, Dr. Daniel M. Blumberger (of the University of Toronto) and his co-authors add to the literature with the largest randomized trial comparing these convulsive therapies conducted and the first non-inferiority clinical trial to address efficacy. The study involved 239 participants with depression. “MST showed non-inferior efficacy relative to… ECT in achieving remission of depression, and a more favourable cognitive safety profile.” We consider the paper and its implications.
Should patients receive prescriptions from an AI prescriber? In the second selection, from JAMA, Dr. Daniel G. Aaron (of the University of Utah) and Christopher Robertson (of Boston University) look at a new Utah program allowing AI to prescribe medications without physician involvement. They are cool to the idea. “Although AI offers the promise of increased efficiency and expanded access, the evasion of legal obligations by early movers raises profound concerns. Incorporating AI into modern health care must be evidence based and responsible.”
And in the third selection, Dr. Jenna Taglienti (of Hofstra University) writes personally about her cancer in JAMA. As a psychiatrist and a residency program director, she finds meaning in her work – but illness helps her gain perspective. “Medicine can have extraordinary meaning. But it cannot substitute for being present in your own life.”
DG
Selection 1: “Confirmatory efficacy and safety trial of magnetic seizure therapy versus right unilateral ultra-brief electroconvulsive therapy in depression (CREST–MST): a randomised, double-blind, non-inferiority trial in Canada and the USA”
Daniel M. Blumberger, Shawn M. McClintock, Kevin E. Thorpe, et al.
The Lancet Psychiatry, May 2026
A large proportion of individuals with major depressive disorder (MDD) experience treatment-resistant depression (TRD) and have little to no benefit from multiple medication trials. Electroconvulsive therapy (ECT) is an effective treatment in patients with TRD, yet only 1% accept treatment, due largely to negative perceptions and cognitive adverse effects. In particular, ECT results in substantial post-ictal disorientation, and anterograde and retrograde amnesia. The extent of anterograde and retrograde amnesia remains a considerable challenge for individuals and their families. Efforts to lessen the cognitive adverse effects of ECT while retaining its efficacy have led to treatment advancements such as right unilateral (RUL) and RUL ultra-brief pulse-width (RUL-UB) ECT…
Magnetic seizure therapy (MST) is an emerging form of convulsive therapy that also produces antidepressant effects by inducing a therapeutic seizure. However, MST differs from ECT as it uses a magnetic field to induce a therapeutic seizure. This is a key advance as magnetic stimulation is not impeded or shunted by non-conducting material (eg, the skull) and can achieve more focal brain activation compared with ECT. In fact, compared with RUL-UB ECT, MST is 5–10 times more focal and spares medial temporal structures linked to the cognitive adverse effects of ECT. Several studies of MST have found favourable antidepressant effects, reductions in suicidal ideation, and minimal cognitive adverse effects. Of note, a blinded randomised study that compared MST with RUL-UB ECT showed similar efficacy in MDD and a superior cognitive safety profile for MST. However, the trial was not designed to test non-inferiority.
Here’s what they did:
- They conducted a “a randomised, double-blind, parallel-group non-inferiority clinical trial with two treatment arms conducted at three academic medical centres: the Centre for Addiction and Mental Health in Toronto, ON, Canada, University of Texas Southwestern Medical Center in Dallas, TX, USA, and University of California, San Diego, CA, USA.”
- They included adults with non-psychotic depression who had a baseline 24-item Hamilton Rating Scale for Depression (HRSD-24) score of 21 or more.
- They received treatment until they achieved remission, dropped out, or up to 21 total treatments. Treatment was either ECT (RUL-UB) or MST (delivered using a twin coil in a midline frontal position).
- Primary outcomes: “Remission of depression on the Hamilton Rating Scale for Depression-24 item and worsening of autobiographical memory on the Autobiographical Memory Test (AMT)… The non-inferiority margin was 15% absolute difference in remission rates and AMT worsening was defined as 25% reduction…”
Here’s what they found:
- 292 participants were enrolled, with 239 randomly assigned.
- Demographics. RUL-UB ECT: participants had a mean age of 45.5 years with 80% being White and 55%, female. MST: participants had a mean age of 44.5 years with 85% being White and 60%, female.
- Remission. “The difference in remission rates was 5.3% in favour of RUL-UB ECT (27.8%) compared with MST (22.5%), establishing non-inferiority of MST (Z-test p=0.048…).”
- Memory. “More RUL-UB ECT participants had worsening autobiographical memory (17.3%) compared with MST participants (2.7%…).” (!!)
- Adverse events. 12 participants in the RUL-UB ECT group and three participants in the MST group withdrew due to adverse events. None were serious.
A few thoughts:
1. This is an excellent study, with a practical question, published in a major journal. There is much to like, including the RCT design.
2. The main finding in a sentence: “This confirmatory efficacy trial found that MST had a numerically lower remission rate that was non-inferior to RUL-UB ECT in achieving depression symptom remission based on the a-priori defined non-inferiority margin of 15%.” To speak less technically: MST was comparable to ECT (in non-inferiority) with less negative effect on memory.
3. Wow.
4. In the future, it’s possible that patients will be offered an alternative to ECT that, unlike rTMS, is clinically comparable.
5. What about suicide? The authors comment: “ECT is one of the few treatments that can rapidly and reliably reduce suicidality and suicide death in MDD. The results of this trial suggest that the effect of MST on remission of suicidal ideation was non-inferior to ECT and had a more favourable cognitive safety. Thus, MST might serve as a viable and effective intervention for reducing suicidality.”
6. Like all studies, there are limitations. The authors note several, including: “Despite this being the largest trial to date comparing MST and ECT, there were challenges in reaching the intended sample size of 260 completers, and the trial was not powered to perform specific sex or gender analyses.”
7. Past Readings have looked at neuromodulation. A 2024 selection, for example, was a Quick Takes interview with Dr. Daniel Blumberger, the first author of this study, who discussed ECT, MST, and the care for those with treatment-resistant depression. That Reading can be found here:
The full Lancet Psychiatry paper can be found here:
https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(26)00060-X/fulltext
Selection 2: “The First AI Drug Prescriber”
Daniel G. Aaron and Christopher Robertson
JAMA, 13 April 2026 Online First
In January 2026, Utah announced a first-of-its-kind partnership with an artificial intelligence (AI) company to prescribe medications without physician involvement. The system, sold by Doctronic, is designed to conduct a ‘comprehensive medical assessment’ that ‘mirrors the clinical decision-making process a licensed physician would follow.’ Initially focusing on prescription renewals, the software is slated to prescribe almost 200 drugs, including corticosteroids, statins, antidepressants, hormones, and anticlotting agents.
So begins a paper by Aaron and Robertson.
“There are potential benefits to AI prescribing in a world facing a long-term shortage of primary care physicians, as well as certain specialists. Medication nonadherence, thought to be complex and multifactorial, significantly affects mortality and morbidity; for many chronic conditions, the public health goal is ensuring that patients access safe, effective drugs and continue receiving them as long as it is appropriate. A 2018 study found that nonoptimized medication regimens, including nonadherence, cost the US $528.4 billion annually. Between 4% and 31% of patients fail to fill a first prescription, and according to a 2009 study, of those who fill a first prescription, approximately 20% fail to obtain a refill. Artificial intelligence could reduce pervasive medication errors, enhance process efficiency, and free physicians to focus on complex diagnostic tasks or human-to-human interactions.”
That said, they also note that technological innovations “can also cause harm, generate waste, and undermine the clinical relationship.” They argue that: “Although physicians must demonstrate competence through rigorous training and board certification, AI prescribers face no equivalent gatekeeper.” The company did offer some data, claiming that in 500 urgent care telehealth cases, “its AI prescriber matched board-certified clinicians’ top primary diagnosis in 81% of instances and treatment decisions in 99.2%.”
The authors focus on legal issues. “Artificial intelligence prescribers are not licensed ‘practitioner[s]’ of medicine; here, Utah has waived state requirements. Utah’s regulatory sandbox waives state laws for businesses with novel ideas deemed potentially beneficial to consumers.” That is also the question of federal oversight. “In the Utah deal, the company made no attempt to approach the FDA about the technology, instead invoking the idea that the FDA does not regulate the practice of medicine. Federal law and the FDA itself express that the FDA does not regulate the practice of medicine. But federal law also reinforces that medical devices and drugs must be legally marketed and used within a legitimate patient-clinician relationship (unless marketed over the counter)…” But they observe a lack of interest on the part of Washington. “The current administration appears to be forgoing federal oversight… Given this antiregulatory environment for AI, the prospect of federal intervention against AI prescribers appears slim, absent significant public pressure.” They worry about the future. “Artificial intelligence prescribing would be safest under concurrent state and federal oversight. Yet Utah has granted a state waiver and FDA compliance has not been demonstrated. Other companies may take the lesson that they can bypass federal safety standards, and they may race into the market to ensure they are not left behind.”
They close on a cautionary note. “Incorporating AI into modern health care must be evidence based and responsible. Physicians and health systems should insist that AI technologies not be allowed to bypass long-standing legal guardrails governing medical products.”
A few thoughts:
1. This is a good Viewpoint, raising important points about Utah.
2. AI could potentially help address problems around access. But is this AI-government partnership rushed? The company’s data involved just 500 people, and the results weren’t published in a scientific journal.
3. Many medications are included, including psychiatric ones. Among them: SSRIs and other antidepressants like bupropion and mirtazapine. Antipsychotics and mood stabilizers aren’t.
4. H/t to Dr. Jay Shore (of the University of Colorado) for the suggestion.
The full JAMA paper can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2847569
Selection 3: “Time Is Finite”
Jenna Taglienti
JAMA, 16 April 2026
I’m going to start with something that might surprise you.
I look young. I look healthy. I look like there is absolutely nothing wrong with me.
I thought I was healthy – a lifelong nonsmoker. A wife and mother of 3. A psychiatrist and residency program director who loves her patients and her residents.
And then I was diagnosed with lung cancer.
So begins a paper by Dr. Taglienti.
She describes her cancer journey. “When I went in for my lobectomy, I did not think I had cancer. Neither did my physicians. The lesion had grown, yes. But statistically? A 45-year-old who never smoked? It was still unlikely. I underwent surgery assuming the lesion might be inflammatory. Perhaps an atypical infection. Maybe something rare but benign.”
She notes that the procedure wasn’t minor, requiring two nights in hospital. Still, she adds: “I was not anxious about the pathology results. Not even a little bit.” Then, ten days later, she opens the patient portal. “The report was already there… I read 1 word: adenocarcinoma. I remember thinking, that can’t be correct. My husband was sitting on the couch watching television. I said it out loud almost casually, as if saying it that way might make it smaller. He took the laptop from me. ‘That’s cancer,’ he said. I stopped reading.
“The shock of that moment still feels physical. The week that followed blurred into appointments, scans, and treatment plans.
“The fear every parent carries quietly moved into the foreground. The possibility of not watching my children grow up was no longer abstract.”
She discusses her treatment and the long hours of chemotherapy. She reconsiders her career. “I loved my job. I still love my job. I poured myself into it – into residents, into patients, into systems. Residents later told me they did not fully understand the depth and importance of our work together until I had left.
“That mattered to me. And yet the program continues. The teaching conferences still happen. The clinics still run. The system adapts to absence.
“That does not diminish the meaning of the work. It simply reminds me that institutions are designed to endure beyond individuals. On the other hand, families are not.”
She thinks about medicine. “I believe in medicine. I believe in training the next generation. I believe in the meaning of this work. What has changed is my willingness to absorb depletion without question.
“The meaning of my work is profound. The meaning of my presence at home is irreplaceable. When confronted with the possibility that time is finite, the hierarchy becomes unmistakable. The tolerance for workplace drama drops. The energy once absorbed by ‘noise’ becomes precious.
“No professional title replaces watching your child grow up. Institutional loyalty does not protect you from what happens when you postpone your own care. Medicine asks a great deal. And we give deeply. But it cannot take everything.”
She closes on a positive note about her cancer – and herself. “I am being treated with curative intent. I am hopeful. I am strong. But I am different now. I am no longer willing to keep postponing life.”
A few thoughts:
1. This is a deeply moving essay.
2. There are many thoughtful lines. This one stands out and is worth repeating: “The meaning of my work is profound. The meaning of my presence at home is irreplaceable.”
3. Dr. Taglienti is a psychiatrist. But the core message is relevant to any physician, of course.
The full JAMA paper can be found here:
https://jamanetwork.com/journals/jama/article-abstract/2847647
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.
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