RUL-UBP ECT in a Large Clinical Sample
Out on PubMed, from researchers at McLean Hospital and the Massachusetts General Hospital, is this study:
Rate of continuing acute course treatment using right unilateral ultrabrief pulse electroconvulsive therapy at a large academic medical center.
And from the text:
...perhaps the most favorable interpretation of these results from the perspective of RUL-UBP ECT is that the method achieves remission in fewer than 12 treatments in approximately 1/3 of patients (reflecting the 571 who discontinue treatment), is unsuccessful in 1/3 of patients (the 616 who require alternative treatment parameters), and is tolerable and partially effective in the remaining 1/3 (the 606 receiving twelve RUL-UBP treatments). A worst-case interpretation could view patients who discontinue treatment as dropping out due to lack of efficacy or side effects, implying even lower effectiveness. The two largest prospective trials of ECT, the CORE and PRIDE trials, both indicate that the mean number of treatments required to reach remission of depression is 7.3, [9, 10]. This is comparable to the mean number of treatments in the patients who discontinue ECT prior to treatment #12 (6.9 among the 571 patients) which suggests that many of this group may in fact have discontinued treatment due to remission
...The results from this study that geriatric patients remained in RUL-UBP treatments at equal rates to younger patients suggests similar tolerability of this treatment methodology across the age span
...Since this study only examines individuals who started treatment with RUL-UBP ECT, the generalizability of this finding may be limited as the most severely ill patients of either diagnosis may have been treated with bilateral or brief pulse treatments, so they would not have been included in this study population. Nonetheless this result is suggestive that, consistent with meta-analysis of prior trials using a variety of ECT stimulus parameters, RUL-UBP can be used similarly in unipolar and bipolar illnesses.
...A further potential source of variability in dosing is that the MECTA ECT instrument permits adjustment of parameters, including pulse width, frequency, and stimulus duration, and that as a result some net doses can be administered in different ways [3]. Among the seven most common doses in this study, only the 230.4 mC dose was administered multiple ways (800 mA, 0.3 ms pulse width, 60 Hz frequency, 8 s duration, administered 5271 times; 800 mA, 0.3 ms pulse width, 80 Hz frequency, 6 s duration, administered 463 times). As there are likely differing effects of amplitude [24], duration [25], and frequency [26] in addition to pulse width, this may contribute to variation in outcomes
This is an impressive piece of data analysis; Dr. Luccarelli and colleagues are to be congratulated for this detailed look at the clinical data from one of the largest ECT services in the country, perhaps the world. Of course, as they correctly point out, without linkage to clinical outcome or tolerability information, the conclusions that can be drawn from these data are limited.
The results suggest good clinical outcomes, but are they good enough? In other words, is the trade-off of better temporary tolerability for the likely reduction in remission rates and speed of response worth it? One assumes that practitioners will have discussed these issues up front with patients, as part of the informed consent, in a collaborative clinical decision-making process.
This paper gives a look into the real-world clinical practice of ECT at a major academic center. The fact that different ECT techniques (including that some more severely ill patients start with bilateral ECT) are offered indicates a commendable, flexible approach to contemporary ECT practice. However, the number who start with bilateral ECT is so small (67/1924) that clearly RUL-UBP ECT has become the de facto standard of care there. In a large ECT service that sees the full range of severity of illness, my estimate has long been that the the split between initial bilateral and RUL electrode placement should be about 50/50. Further research, along the lines of this excellent report, that includes antidepressant efficacy and tolerability data, will help guide the field in the appropriate apportioning of initial electrode placement, balancing illness severity/urgency and the need for definitive, rapid response with tolerability concerns. Has the pendulum swung too far away from BL ECT?
The below comment is from Dr. Luccarelli and colleagues:
ReplyDeleteWe agree that the benefits of initial bilateral vs. unilateral treatment remains an unsolved question, and encourage further research into this. Our usual practice is to start with unilateral treatments for several reasons, some of which may be unique to the population we serve (which is not reflective of all psychiatric patients in Massachusetts, much less the nation or world as a whole):
With many of our patients, particularly those who are particularly sensitive to the cognitive effects of ECT (and this is not always easy to predict) and those worried about memory issues, if they experience significant cognitive effects early on they are more likely to quit before getting a full course. Additionally, for those patients who are very sensitive, if we see that sensitivity with UBP, we know that if we do increase the settings or change to BL placement, we will need to be very careful and perhaps spread out the treatments to twice a week or less. This can help prevent a delirium or intolerable cognitive effects.
We find (as is clear from our previous papers) that continuation ECT is as important as the acute phase of treatment, as without it the relapse rates are high even with good psychopharmacology treatment. Given that we may be treating these patients in a taper for several months, if we can get away with more tolerable ECT, we are more likely to keep them longer in treatment to prevent complete the taper and better prevent relapse
There are some patients who just respond better to unilateral than bilateral. We admit that statistically BL has faster, more robust response/remission rates, but there are some patients who feel awful with bilateral and respond better to unilateral. By starting with RUL-UBP, transitioning to RUL-BP and then to BL (or bifrontal in some cases), patients get the full range of treatment options before we say the treatment is not effective.
Thank you, Dr. Luccarelli and colleagues, your points are well taken.
ReplyDeleteI believe the crux of the argument is still based on urgency of clinical presentation- the more urgently ill a patient is, the more bilateral electrode placement should be favored. I wrote in the Handbook of ECT (p.50), "...Patients who want to be assured of receiving the most powerful and effective form of treatment may express a preference for bilateral over unilateral ECT. Finally, patients with severe medical conditions that might increase the risks of repeated anesthesia sessions should be considered for bilateral electrode placement because it is most reliably effective and typically has more rapid therapeutic effects, minimizing the number of anesthesia inductions."