Another Comparison of RUL and BL-from Poland

 Out on Pubmed, from researchers in Warsaw, Poland, is this study:

Efficacy, safety and tolerability of formula-based unilateral vs bilateral electroconvulsive therapy in the treatment of major depression: A randomized open label controlled trial.

Dominiak M, Antosik-Wójcińska AZ, Goetz Z, Sikorska O, Stefanowski B, Gorostiza D, Święcicki Ł.J Psychiatr Res. 2020 Dec 4;133:52-59. doi: 10.1016/j.jpsychires.2020.12.002. Online ahead of print.PMID: 33310500

The abstract is copied below:

Electroconvulsive therapy (ECT) remains the most effective treatment of depression, though it is still unclear which of its type is the most beneficial. The aim of this study was to compare the formula-based right unilateral ECT (RUL) with the fronto-temporal bilateral ECT (BT), in terms of their efficacy, safety and tolerability in patients with bipolar or unipolar depression. Ninety-one patients were randomly assigned to either BT (n = 45) or RUL (n = 46) ECT. Brief pulse width (0.5 ms) and a formula-based dosing method were applied. The clinical efficacy was assessed using the Hamilton Depression Rating Scale (HDRS-21).The somatic state was monitored throughout the ECT course and cognitive examination included: general cognitive performance, executive functions, visual-spatial functions, verbal fluency, verbal memory and autobiographical memory. Efficacy outcomes were not found to be significantly different between groups when using higher doses of energy in RUL ECT. Patients in RUL group were less likely to be confused and experienced increased blood pressure. The indices of general cognitive performance and verbal auditory memory were also significantly better this group, while BT ECT did not change these functions. Both ECT types resulted in a decline in the retrieval consistency of autobiographical memory that persists for at least three months and was significantly more marked in BT group as compared to RUL. In conclusion, formula-based RUL ECT does not differ from BT in antidepressant efficacy and has an advantage in terms of safety (lower incidence of increased blood pressure and fewer disturbances of consciousness) and tolerability (impact on cognitive functions).

Keywords: Autobiographical memory; Bipolar disorder; Cognitive side effects; Depression; Electroconvulsive therapy; Unipolar disorder.

This study adds the interesting methodological feature of using formula-based (actually, just age based) stimulus dosing in a comparison of RUL and BT ECT. The conclusions are not surprising, but the design shortcomings of the study limit their strength. There was no treatment blinding and assessments were made at only two time points (so it unclear how the end of the ECT course was determined). The remission rate is very low compared with the response rate, for unknown reasons. The dosing was up to 1008 mC (European Thymatron device).

My take on this, and the accumulated evidence already in the literature, is that RUL ECT is pretty good, and perhaps equally good as BT for many patients (as shown by group data). I think the caveat that RUL is not as powerful as BT for a minority of patients needs to be repeated, so that the practice of switching to BL when RUL is ineffective or slow, remains standard of care.

I would be interested to hear what others think of this study. Thanks.