To achieve therapeutic efficacy in electroconvulsive therapy (ECT), adequate seizures must be induced by electrical stimulation. However, in some cases, even maximum output stimulation of the treatment devices used in Japan fails to induce seizures, making the management of such difficult-to-induce cases an important clinical issue. Right unilateral (RUL) ECT is known to reduce cognitive impairment but is also associated with a low seizure threshold, making it useful in cases in which seizure induction is difficult. Additionally, previous case reports have described the successful enhancement of seizures in bilateral (BL) ECT with pulse width lengthening. We herein present a case of severe depression in which BL ECT failed to induce seizures even with stimulation at the maximum output. We successfully induced adequate seizures and achieved the remission of symptoms by switching to RUL ECT and pulse width lengthening. The combination of RUL ECT and pulse width lengthening may be a promising method for seizure augmentation in difficult-to-induce cases; however, further validation of its efficacy is warranted, taking into account the individuality of each case.
 Authors' abstract