Abrams' Classic 1983 Comparison of Bilateral vs Unilateral ECT
"Classics in ECT" today brings you this clinical trial from 1983, authored by noted ECT researcher and scholar, Richard (Dick) Abrams and colleagues including Mickey Taylor and Ray Faber:
Bilateral versus unilateral electroconvulsive therapy: efficacy in melancholia.
Bilateral versus unilateral electroconvulsive therapy: efficacy in melancholia.
Am J Psychiatry. 1983 Apr;140(4):463-5. doi: 10.1176/ajp.140.4.463.PMID: 6837786
The abstract is at the above link and copied here:
The authors compared the therapeutic efficacy of bilateral and unilateral electroconvulsive therapy (ECT) in 51 patients with endogenous depression who were randomly assigned to bilateral (N = 24) or unilateral (N = 27) ECT. Seizures were monitored by oscilloscope. After 6 treatments blind assessment on a modified Hamilton depression scale showed an 81.1% improvement in the bilateral group compared with a 55.5% improvement in the unilateral group. Additional treatments were prescribed ad libitum by a hospital psychiatrist who was unaware of each patient's electrode placement. The unilateral group received more total treatments and were more frequently switched to bilateral ECT. These results were independent of age, severity of illness, or sedative drug administration.
The pdf is here.
I remind you of this classic study to again highlight the clear writing style of Dr. Abrams and to remind us of a simpler time (not necessarily better) in ECT research. Although the authors tout the superiority of bilateral ECT, they also point out that one third of their RUL patients achieved HAM-D scores of 2 or less, and 41% received a total of only 6 treatments. Some archaic study features were use of sinusoidal currents and the Lancaster position for the RUL placement.
I conclude (based on this and the back-and-forth discussions and data of the ensuing nearly 40 years) that both RUL and BL electrode placements are very effective antidepressant treatments, with somewhat different efficacy/tolerabilty/speed of action profiles.
Please see blog post of 3/26/2020 for the high-dose RUL study of a decade later...
The abstract is at the above link and copied here:
The authors compared the therapeutic efficacy of bilateral and unilateral electroconvulsive therapy (ECT) in 51 patients with endogenous depression who were randomly assigned to bilateral (N = 24) or unilateral (N = 27) ECT. Seizures were monitored by oscilloscope. After 6 treatments blind assessment on a modified Hamilton depression scale showed an 81.1% improvement in the bilateral group compared with a 55.5% improvement in the unilateral group. Additional treatments were prescribed ad libitum by a hospital psychiatrist who was unaware of each patient's electrode placement. The unilateral group received more total treatments and were more frequently switched to bilateral ECT. These results were independent of age, severity of illness, or sedative drug administration.
The pdf is here.
I remind you of this classic study to again highlight the clear writing style of Dr. Abrams and to remind us of a simpler time (not necessarily better) in ECT research. Although the authors tout the superiority of bilateral ECT, they also point out that one third of their RUL patients achieved HAM-D scores of 2 or less, and 41% received a total of only 6 treatments. Some archaic study features were use of sinusoidal currents and the Lancaster position for the RUL placement.
I conclude (based on this and the back-and-forth discussions and data of the ensuing nearly 40 years) that both RUL and BL electrode placements are very effective antidepressant treatments, with somewhat different efficacy/tolerabilty/speed of action profiles.
Please see blog post of 3/26/2020 for the high-dose RUL study of a decade later...
The below comment is from Ray Faber, one of the authors of this article:
ReplyDeleteGood choice of article to present. I certainly remember the study and atmosphere at the time.
To say that Dick and Mickey were ECT enthusiasts would be an understatement. The preponderance of treated patients had melancholia or melancholic aspects in their presentation. The population came from inpatients at the North Chicago VA. I don't recall treating outpatients or doing maintenance. Obviously, the polar opposite of how ECT is now done. In retrospect, I think we could have used it even more for psychosis, especially in the pre-clozapine era. Personally, I will always be in Dick's debt for instructing me in all the fine points of ECT. I was a blind rater for the study. I was actually slightly surprised by the results because it seemed like the preponderance of patients did very well. Seemed like not enough did poorly, so that even if those were all unilateral, that there would be much of a difference. This doesn't diminish my confidence in the results, however.
As an aside, I remember at one point Dick telling me how simple the components of an ECT device were. He went on about capacitors and such with surprising enthusiasm. A year or two later Somatics was born.
Digressing even more, I met Dick and Mickey early in my residency at New York Medical College based at Metropolitan Hospital. Each made a hugely positive impression on me. Of course they stood out in a faculty dominated by psychoanalysts. Dick once tried to make a bet with Irving Bieber, analyst of some renown, that he could get better results with lithium than could be achieved by therapy. Kind of bizarre really and I don't recall specifics. I had breakfast with Dick and Mickey in the hospital cafeteria on numerous occasions. They'd usually discuss their research, which was in fact seminal, along with fly fishing.
Wonder if you are familiar with Mickey's book, Hippocrates Cried. It's really a good history of the last 50 years of psychiatry. Pretty funny in parts.
Ray Faber, MD