A Safer and Equally Effective Approach to ECT

Electroconvulsive therapy (ECT) remains the most effective intervention for treatment-resistant major depression. Studies comparing ECT applications have differed in ECT technique and patient samples, yielding inconsistent results, but bilateral treatments have generally been more effective than unilateral ones. However, bilateral ECT often results in greater memory loss, contributing to some patients' and families' reluctance to use ECT. Investigators in Ireland randomized 138 patients with very severe depression to ≤12 sessions of twice-weekly, brief-pulse, high-dose unilateral ECT (6× seizure threshold) or moderate-dose, standard bitemporal ECT (1.5× seizure threshold).

In this pragmatic, double-blind study, patients (female, 63%; mean age, 57; median length of depressive episode, 20 weeks) were referred for ECT mostly for medication nonresponse (54%) or need for rapid response (41%). Randomization was stratified by age (above or below age 65), previous or initial ECT, and referral site. Patients continued their ongoing medications; 21% had psychosis, and 23% had bipolar disorder (all equivalently assigned between treatments).

After the end of the ECT course, unilateral ECT was noninferior to bitemporal ECT. The approaches had comparable rates of response (unilateral ECT, 61%; bitemporal ECT, 51%) and remission (46% and 42%). At 6-month follow-up, relapse rates did not differ (25% and 38%). Bitemporal ECT was associated with worse recall of baseline autobiographical memories at end of treatment through 6-month follow-up (odds ratios, 0.59–0.66). Unilateral-ECT patients reported fewer cognitive adverse effects through 6-month follow-up. Physical adverse events showed no between-group differences.