Sticking With RUL Electrode Placement: New Retrospective Data
Out on PubMed, in JECT, from researchers in Boston, is this study:
Duration of Treatment in Electroconvulsive Therapy Among Patients Beginning With Acute Course Right Unilateral Brief Pulse Stimuli.
J ECT. 2021 Apr 9. doi: 10.1097/YCT.0000000000000768. Online ahead of print.PMID: 33840804
The abstract is copied below:
Objectives: Right unilateral brief pulse (RUL-BP) electroconvulsive therapy (ECT) has been adopted as a technique for reducing the cognitive side effects of ECT relative to sine wave or bilateral treatments, but it is unknown how often patients are transitioned to alternative electrode placements. This study analyzes time in first lifetime acute course RUL-BP ECT.
Methods: A single-center retrospective chart review was conducted of adult patients receiving a first lifetime course of ECT from 2000 to 2017 beginning with individualized seizure threshold determination using RUL-BP treatment parameters.
Results: A total of 1383 patients met study criteria and received a mean number of 9.4 ± 3.1 treatments, of which 7.6 ± 3.3 were using RUL-BP stimuli. Only 37.5% of patients were transitioned from RUL to bilateral treatments. Younger patients and those diagnosed with bipolar disorder were more likely to transition from RUL-BP to bilateral treatments, but the overall number of treatments did not differ based on age or primary diagnosis.
Conclusions: Among patients who begin treatment with RUL-BP ECT, more than 60% use exclusively those parameters throughout their acute course.
and from the text:
A total of 3860 patients began ECT during the study period,
of whom 170 began with bilateral treatments and 2307 began with
RUL UBP treatments, leaving 1383 patients who met inclusion
criteria. These patients had a mean age of 49.4 ± 16.9 years
(Table 1). Men (588) made up 42.5% of the sample. Diagnoses
were unipolar depression (1008; 72.9%), bipolar disorder (211;
15.3%), other (70; 5.1%), and missing (94; 6.8%). Anesthetics
used were methohexital (1165; 85.0%), thiopental (128; 9.3%),
propofol (73; 5.3%), and etomidate (5; 0.4%). Participants received a mean of 9.4 ± 3.1 ECT treatments, of which a mean of
7.6 ± 3.3 were RUL-BP treatments. Most patients received ECT
3 times a week...
This is another very interesting paper from Dr. Luccarelli and colleagues at McLean Hospital/Mass General. An impressively large cohort of patients makes for huge amounts of data to analyse, and this particular analysis is quite informative. The take home message is that, in this particular real-world setting,RUL-BP ECT seems to work pretty well. The authors are very clear that these are naturalistic data, with clinician-driven choices, not study protocols. Thus, they are a snapshot of what happened, not necessarily recommendations for optimal practice. The assumption is that the outcomes were very good, but outcome and cognitive data are not included here. It would be interesting to see how ultrabrief pulse starters fared, as well. I note the very small number of patients who started with bilateral electrode placement, a reflection of a practice pattern that might be different at other hospitals, perhaps with a different patient mix.
This paper deserves a full and careful read,~20minutes. I look forward to further contributions to the literature from Dr. Luccarelli and colleagues.
The below comment is from Dr. Luccarelli:
ReplyDeleteI appreciate your kind coverage of our most recent JECT article on your blog this week.
https://ectpsych.blogspot.com/2021/04/sticking-with-rul-electrode-placement.html
Regarding ultrabrief starters, I fully agree that the brief vs. ultrabrief question is an important one. We covered the ultrabrief patients in a previous study:
https://pubmed.ncbi.nlm.nih.gov/33196856/
Blog post: https://ectpsych.blogspot.com/2020/11/rul-ubp-ect-in-large-clinical-sample.html
Our general clinical practice has changed considerably between 2000 and 2017 (the period covered by the dataset), going from predominantly RUL-BP to predominantly RUL-UBP. At the same time, however, we have also massively increased our clinical volume and had significant changes in referral patterns (in age, diagnosis, and acuity among others). As a result we felt the data were best presented separately to avoid making direct comparisons between the RUL-BP and RUL-UBP starters, because ultimately we don't think the two groups can be meaningfully compared due to confounding with all the other changes. We very much hope that other centers may have different practices and would love to hear from colleagues around the world their experiences with the two techniques (and even better, with bilateral starters as well).