"Classics in ECT" today features this review by d'Elia and Raotma from the British Journal of Psychiatry in 1975:
Br J Psychiatry. 1975 Jan;126:83-9. Is unilateral ECT less effective than bilateral ECT? d'Elia G, Raotma H. PMID: 1092400
The pdf is here.
The authors (yes, the d'Elia who originated the nearly universally used placement for RUL)
review the studies up to that time comparing the efficacy of bilateral versus unilateral electrode placement. They come down strongly on the side of declaring equal efficacy between the two techniques; they also suggest that when RUL appears inferior, it is because it has not been technically optimized.
The pdf is here.
The authors (yes, the d'Elia who originated the nearly universally used placement for RUL)
review the studies up to that time comparing the efficacy of bilateral versus unilateral electrode placement. They come down strongly on the side of declaring equal efficacy between the two techniques; they also suggest that when RUL appears inferior, it is because it has not been technically optimized.
All of this, of course, preceded the studies of Harold Sackeim that further promulgated the concept of dose above seizure threshold to optimize efficacy of RUL. The debate about the relative merits of the two techniques continues to this day, and at times has unnecessarily divided the field.
My view is that, in group data, RUL is slightly less effective and takes slightly longer to work than BL. That said, it is perfectly fine for the many patients for whom it is fully effective. But it doesn't work for all patients, and for those, practitioners should be willing to switch to BL placement when RUL is not working after several treatments. If one considers RUL ECT a "less strong" form of ECT, a medication analogy is apt: if, say 20 mg of a medication works for most patients, then there is no need to give everyone 80 mg; but importantly, if the lower dose is ineffective for an individual patient, the higher dose is indicated.
(Please see also post of May 18 for latest on cognitive functions and ECT)
The below comment is from Max Fink:
ReplyDeleteRUL vs BT, again
In the early days of ECT and psychopharm, we were learning. At Hillside, Klein and Kramer concluded that 1200 mg CPZ and 300 IMI were effective doses. These doses, became the basis for our RCT. In an RCT study in 1957, we reported that RUL ECT was less effective that BT. (We also reported that sham ECT was ineffective compared to BT ECT). Abrams and Volavka repeated the BT>RUL finding in1972/3, and CORE studies did again in 2000s. Volavka in1970s showed RUL induced lesser slowing in EEG; Fink in 1957 had shown the relationship between high degrees of EEG slowing and recovery; the EEG measure documents the lesser benefits of RUL. Considering neuroendocrine theory, RUL ECT elicits lesser degrees of Prolactin and ACTH release than BT. A clue to the lesser efficacy? The issues in RUL vs BT not covered in the d'Elia and Raotma study are:
Currents and dosing were higher, before the introduction of brief pulse currents in 1980s. Dosing for RUL was higher in d'Elia study than today. ST dosing came in decades after this study. ST dosing weakens a treatment course because Rx #1 is ineffective, by definition, not at 6xST. RUL Rx is ineffective in catatonia, manic delirium, NMS. (The clinician having decided that ECT is necessary, often because condition is life threatening, what is the risk of the delays of RUL inefficacy?) Suicide risk relief by ECT requires 3-6 seizures; a gamble of unmeasured consequence in the weeks of no relief?
And, the cognitive disadvantage of BT is transient and exaggerated. Cost-benefit analysis argues against the use of RUL.
Max Fink, M.D.