Unilateral Equal to Bitemporal ECT in Depression

Pam Harrison

September 03, 2015

AMSTERDAM — High-dose unilateral electroconvulsive therapy (ECT) is as effective as the more conventional bitemporal approach and is associated with fewer cognitive effects, especially autobiographic memory, the most controversial side effect associated with ECT, a randomized comparison of the two modes suggests.

The study was presented here during the 28th European College of Neuropsychopharmacology (ECNP) Congress.

"Convention in the United Kingdom has been to use bitemporal ECT, and this was based on the UK's ECT group's meta-analysis in the Lancet about 10 years ago, where they found bitemporal ECT was much better than unilateral," Declan McLoughlin, MD, Trinity College Institute of Neurosciences, Dublin, Ireland, told delegates here.

"But this was before many new studies were done comparing the two, including our own, and certainly it would now appear that unilateral is just as good as bitemporal ECT, but unilateral ECT has some cognitive advantages," he said.

"So if you are discussing treatment options with a patient, you need to give them this information so they can make a choice about what they want."

Noninferiority Trial

The EFFECT-Dep trial was a noninferiority pragmatic study designed to reflect real-world practice of ECT. A total of 140 patients with major depression were randomly assigned in equal numbers to high-dose right unilateral ECT (6 x seizure threshold [ST]) or to standard bitemporal ECT (1.5 x ST) for as many ECT sessions required to achieve a good response.

Patients had either unipolar or bipolar depression, and about 20% of the patients had some element of psychosis.

"We gave ECT twice a week," Dr McLoughlin said. "In the first session, we established a seizure threshold, looking for a minimal charge, and after that, bilateral was given at fives times the seizure threshold and unilateral at six times the seizure threshold."

Patients received a maximum of 12 ECT sessions, but most patients received eight sessions in both treatment groups.

The primary outcome was change in the 24-item Hamilton Depression Rating Scale after the course of ECT. Secondary outcomes included various measures of cognition.

"There was no difference in either response or remission rates nor in relapse rates between the two groups," Dr McLoughlin reported.

The overall response rate was 57%, and the overall remission rate was 44%, he added.

There was also no significant difference between the two groups in relapse rates at 3 or 6 months' follow-up, although numerically, the unilateral group appeared to do better than the bilateral group.

"When we looked at cognitive side effects, there was an advantage for the unilateral group in terms of immediate recovery of orientation after individual treatments during the course of ECT at 19 minutes vs 26 minutes for the bitemporal group," Dr McLoughlin observed.

It was previously reported that delayed time to orientation after an ECT session predicts cognitive problems, such as amnesia over time.

Consistency of recall of baseline memories was 35% lower in the group receiving bilateral ECT at the end of treatment (OR, 0.65; P = .001). This was maintained at both 3 and 6 months' follow-up (OR, 0.59; P < 001 for both time points).

Investigators did not detect any significant differences in other cognitive measures between the two groups with the exception of immediate verbal recall, which was superior in the unilateral group for the first 3 months, after which the difference disappeared.

"At the moment, we are changing our practice and are suggesting that if a patient is referred for treatment-resistant depression, the most common indication for ECT, then to start off with high-dose unilateral ECT, especially if patients have cognitive issues to begin with," Dr McLoughlin observed.

No One Single Technique

Commenting on the study, Pascal Sienaert, MD, PhD, Catholic University of Leuven, Belgium, cautioned that he does not think there is any one single ECT technique that should be considered standard of care at the moment, at least not on the basis of findings to date.

"I think the data give us some possibilities to tailor treatment to patients and to show a treatment technique that is more or less of use in this or that patient," he said.

"So the question in my mind to answer is not what is the single most efficacious and safe treatment technique, because I don't think there is one, but which patients will respond faster to ECT and which patients will experience cognitive effects and why."

Dr McLoughlin and Dr Sienaert have disclosed no relevant financial relationships.

28th European College of Neuropsychopharmacology (ECNP) Congress. Abstract S.05.01. Presented August 30, 2015.

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