Hostname: page-component-5b777bbd6c-w6wnr Total loading time: 0 Render date: 2025-06-23T15:03:13.566Z Has data issue: false hasContentIssue false
  • English
  • Français

Bitemporal v. high-dose right unilateral electroconvulsive therapy for depression: a systematic review and meta-analysis of randomized controlled trials

Published online by Cambridge University Press:  26 October 2016

E. Kolshus ,
A. Jelovac  and
D. M. McLoughlin
E. Kolshus
Affiliation:
Department of Psychiatry, Trinity College Dublin, St Patrick's University Hospital, Dublin, Ireland Trinity College Institute of Neuroscience, Trinity College Dublin, Ireland
A. Jelovac
Affiliation:
Department of Psychiatry, Trinity College Dublin, St Patrick's University Hospital, Dublin, Ireland
D. M. McLoughlin*
Affiliation:
Department of Psychiatry, Trinity College Dublin, St Patrick's University Hospital, Dublin, Ireland Trinity College Institute of Neuroscience, Trinity College Dublin, Ireland
*
*Address for correspondence: Dr D. M. McLoughlin, Department of Psychiatry, Trinity College Dublin, St Patrick's University Hospital, James's Street, Dublin 8, Ireland. (Email: d.mcloughlin@tcd.ie)
Get access Rights & Permissions [Opens in a new window]

Abstract

Background

Brief-pulse electroconvulsive therapy (ECT) is the most acutely effective treatment for severe depression though concerns persist about cognitive side-effects. While bitemporal electrode placement is the most commonly used form worldwide, right unilateral ECT causes less cognitive side-effects though historically it has been deemed less effective. Several randomized trials have now compared high-dose (>5× seizure threshold) unilateral ECT with moderate-dose (1.0–2.5× seizure threshold) bitemporal ECT to investigate if it is as effective as bitemporal ECT but still has less cognitive side-effects. We aimed to systematically review these trials and meta-analyse clinical and cognitive outcomes where appropriate.

Method

We searched PubMed, PsycINFO, Web of Science, Cochrane Library and EMBASE for randomized trials comparing these forms of ECT using the terms ‘electroconvulsive’ OR ‘electroshock’ AND ‘trial’.

Results

Seven trials (n = 792) met inclusion criteria. Bitemporal ECT did not differ from high-dose unilateral ECT on depression rating change scores [Hedges's g = −0.03, 95% confidence interval (CI) −0.17 to 0.11], remission (RR 1.06, 95% CI 0.93–1.20), or relapse at 12 months (RR 1.42, 95% CI 0.90–2.23). There was an advantage for unilateral ECT on reorientation time after individual ECT sessions (mean difference in minutes = −8.28, 95% CI −12.86 to −3.70) and retrograde autobiographical memory (Hedges's g = −0.46, 95% CI −0.87 to −0.04) after completing an ECT course. There were no differences for general cognition, category fluency and delayed visual and verbal memory.

Conclusions

High-dose unilateral ECT does not differ from moderate-dose bitemporal ECT in antidepressant efficacy but has some cognitive advantages.

Keywords

Depressionelectroconvulsive therapyelectrode placementmeta-analysis
Type
Original Articles
Information
Psychological Medicine , Volume 47 , Issue 3 , February 2017 , pp. 518 - 530
Copyright
Copyright © Cambridge University Press 2016 

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

Article purchase

Temporarily unavailable

References

Borenstein, M (2009). Introduction to Meta-Analysis. Wiley: Oxford.Google Scholar
Buschke, H (1973). Selective reminding for analysis of memory and learning. Journal of Verbal Learning and Verbal Behavior 12, 543–550.Google Scholar
DerSimonian, R, Laird, N (1986). Meta-analysis in clinical trials. Controlled Clinical Trials 7, 177–188.Google Scholar
Dunne, RA, McLoughlin, DM (2012). Systematic review and meta-analysis of bifrontal electroconvulsive therapy versus bilateral and unilateral electroconvulsive therapy in depression. The World Journal of Biological Psychiatry 13, 248–258.Google Scholar
Feighner, JP, Robins, E, Guze, SB, Woodruff, R Jr., Winokur, G, Munoz, R (1972). Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry 26, 57–63.Google Scholar
Fink, M (2014). What was learned: studies by the consortium for research in ECT (CORE) 1997–2011. Acta Psychiatria Scandinavica 129, 417–426.Google Scholar
Folstein, MF, Folstein, SE, McHugh, PR (1975). ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12, 189–198.Google Scholar
Food and Drug Administration (2011). FDA Executive Summary Prepared for the January 27–28, 2011 meeting of the Neurological Devices Panel. (http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/NeurologicalDevicesPanel/UCM240933.pdf). Accessed 1 July 2015.Google Scholar
Freeman, CP (2013). Cognitive adverse effects of ECT. In The ECT Handbook (ed. Waite, J., Easton, A.), pp. 76–86. RCPsych Publications: London.Google Scholar
Geddes, LA (1987). Optimal stimulus duration for extracranial cortical stimulation. Neurosurgery 20, 94–99.CrossRefGoogle ScholarPubMed
Hannay, HJ, Levin, HS (1985). Selective reminding test: an examination of the equivalence of four forms. Journal of Clinical and Experimental Neuropsychology 7, 251–263.CrossRefGoogle ScholarPubMed
Higgins, J, Green, SP (2008). Cochrane Handbook for Systematic Reviews of Interventions. Wiley-Blackwell: Oxford.Google Scholar
Higgins, JP, Altman, DG, Gotzsche, PC, Juni, P, Moher, D, Oxman, AD, Savovic, J, Schulz, KF, Weeks, L, Sterne, JA, Cochrane Bias Methods Group, Cochrane Statistical Methods Group (2011). The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. British Medical Journal 343, d5928.Google Scholar
Ingram, A, Saling, MM, Schweitzer, I (2008). Cognitive side effects of brief pulse electroconvulsive therapy: a review. The Journal of ECT 24, 3–9.Google Scholar
Janicak, PG, Davis, JM, Gibbons, RD, Ericksen, S, Chang, S, Gallagher, P (1985). Efficacy of ECT: a meta-analysis. American Journal of Psychiatry 142, 297–302.Google Scholar
Jelovac, A, Kolshus, E, McLoughlin, DM (2013). Relapse following successful electroconvulsive therapy for major depression: a meta-analysis. Neuropsychopharmacology 38, 2467–2474.Google Scholar
Jelovac, A, O'Connor, S, McCarron, S, McLoughlin, DM (2016). Autobiographical memory specificity in major depression treated with electroconvulsive therapy. Journal of ECT 32, 38–43.Google Scholar
Kellner, CH, Knapp, R, Husain, MM, Rasmussen, K, Sampson, S, Cullum, M, McClintock, SM, Tobias, KG, Martino, C, Mueller, M, Bailine, SH, Fink, M, Petrides, G (2010). Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial. British Journal of Psychiatry 196, 226–234.Google Scholar
Lancaster, NP, Steinert, RR, Frost, I (1958). Unilateral electro-convulsive therapy. Journal of Mental Science 104, 221–227.Google Scholar
Lau, J, Ioannidis, JP, Terrin, N, Schmid, CH, Olkin, I (2006). The case of the misleading funnel plot. British Medical Journal 333, 597–600.Google Scholar
Lee, WH, Deng, ZD, Kim, TS, Laine, AF, Lisanby, SH, Peterchev, AV (2012). Regional electric field induced by electroconvulsive therapy in a realistic finite element head model: influence of white matter anisotropic conductivity. Neuroimage 59, 2110–2123.CrossRefGoogle Scholar
Leiknes, KA, Jarosh-von Schweder, L, Hoie, B (2012). Contemporary use and practice of electroconvulsive therapy worldwide. Brain and Behavior 2, 283–344.Google Scholar
Letemendia, FJ, Delva, NJ, Rodenburg, M, Lawson, JS, Inglis, J, Waldron, JJ, Lywood, DW (1993). Therapeutic advantage of bifrontal electrode placement in ECT. Psychological Medicine 23, 349–360.CrossRefGoogle ScholarPubMed
Lezak, MD (2012). Neuropsychological Assessment. Oxford University Press: Oxford; New York.Google Scholar
Loo, CK, Katalinic, N, Martin, D, Schweitzer, I (2012). A review of ultrabrief pulse width electroconvulsive therapy. Therapeutic Advances in Chronic Disease 3, 69–85.Google Scholar
Martin, DM, Galvez, V, Loo, CK (2015). Predicting retrograde autobiographical memory changes following electroconvulsive therapy: relationships between individual, treatment, and early clinical factors. International Journal of Neuropsychopharmacology 18, pyv067.CrossRefGoogle ScholarPubMed
Mayeux, R, Stern, Y, Rosen, J, Leventhal, J (1981). Depression, intellectual impairment, and Parkinson disease. Neurology 31, 645–650.Google Scholar
McCall, WV, Dunn, A, Rosenquist, PB, Hughes, D (2002). Markedly suprathreshold right unilateral ECT versus minimally suprathreshold bilateral ECT: antidepressant and memory effects. Journal of ECT 18, 126–129.Google Scholar
McCall, WV, Reboussin, DM, Weiner, RD, Sackeim, HA (2000). Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Archives of General Psychiatry 57, 438–444.Google Scholar
McClintock, SM, Choi, J, Deng, ZD, Appelbaum, LG, Krystal, AD, Lisanby, SH (2014). Multifactorial determinants of the neurocognitive effects of electroconvulsive therapy. Journal of ECT 30, 165–176.Google Scholar
McElhiney, MC, Moody, BJ, Sackeim, HA (2001). The Autobiographical Memory Interview - Short Form. Department of Biological Psychiatry, New York State Psychiatric Institute: New York.Google Scholar
McElhiney, MC, Moody, BJ, Steif, BL, Prudic, J, Devanand, DP, Nobler, MS, Sackeim, HA (1995). Autobiographical memory and mood: effects of electroconvulsive therapy. Neuropsychology 9, 501–517.Google Scholar
Moher, D, Liberati, A, Tetzlaff, J, Altman, DG, Prisma Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. British Medical Journal 339, b2535.Google Scholar
Mungas, D (1983). Differential clinical sensitivity of specific parameters of the Rey Auditory-Verbal Learning Test. Journal of Consulting and Clinical Psychology 51, 848–855.Google Scholar
NICE (2009). Depression: the treatment and management of depression in adults. NICE Clinical Guideline. National Institiute for Health and Clinical Excellence: London.Google Scholar
O'Connor, DW, Gardner, B, Eppingstall, B, Tofler, D (2010). Cognition in elderly patients receiving unilateral and bilateral electroconvulsive therapy: a prospective, naturalistic comparison. Journal of Affective Disorders 124, 235–240.CrossRefGoogle ScholarPubMed
Pettinati, HM, Mathisen, KS, Rosenberg, J, Lynch, JF (1986). Meta-Analytical approach to reconciling discrepancies in efficacy between bilateral and unilateral electroconvulsive therapy. Convulsive Therapy 2, 7–17.Google Scholar
Ranjkesh, F, Barekatain, M, Akuchakian, S (2005). Bifrontal versus right unilateral and bitemporal electroconvulsive therapy in major depressive disorder. Journal of ECT 21, 207–210.CrossRefGoogle ScholarPubMed
Rasmussen, KG, Zorumski, CF, Jarvis, MR (1994). Possible impact of stimulus duration on seizure threshold in ECT. Convulsive Therapy 10, 177–180.Google Scholar
Rey, A (1964). L'Examen Clinique en Psychologie. Press Universitaire de France: Paris.Google Scholar
Rush, AJ, Trivedi, MH, Wisniewski, SR, Nierenberg, AA, Stewart, JW, Warden, D, Niederehe, G, Thase, ME, Lavori, PW, Lebowitz, BD, McGrath, PJ, Rosenbaum, JF, Sackeim, HA, Kupfer, DJ, Luther, J, Fava, M (2006). Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. American Journal of Psychiatry 163, 1905–1917.Google Scholar
Ryan, JJ, Geisser, ME, Randall, DM, Georgemiller, RJ (1986). Alternate form reliability and equivalency of the Rey Auditory Verbal Learning Test. Journal of Clinical and Experimental Neuropsychology 8, 611–616.Google Scholar
Sackeim, HA (2014). Autobiographical memory and electroconvulsive therapy: do not throw out the baby. Journal of ECT 30, 177–186.Google Scholar
Sackeim, HA, Decina, P, Kanzler, M, Kerr, B, Malitz, S (1987). Effects of electrode placement on the efficacy of titrated, low-dose ECT. American Journal of Psychiatry 144, 1449–1455.Google Scholar
Sackeim, HA, Dillingham, EM, Prudic, J, Cooper, T, McCall, WV, Rosenquist, P, Isenberg, K, Garcia, K, Mulsant, BH, Haskett, RF (2009). Effect of concomitant pharmacotherapy on electroconvulsive therapy outcomes: short-term efficacy and adverse effects. Archives of General Psychiatry 66, 729–737.Google Scholar
Sackeim, HA, Portnoy, S, Neeley, P, Steif, BL, Decina, P, Malitz, S (1986). Cognitive consequences of low-dosage electroconvulsive therapy. Annals of the New York Academy of Sciences 462, 326–340.Google Scholar
Sackeim, HA, Prudic, J, Devanand, DP, Kiersky, JE, Fitzsimons, L, Moody, BJ, McElhiney, MC, Coleman, EA, Settembrino, JM (1993). Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. New England Journal of Medicine 328, 839–846.Google Scholar
Sackeim, HA, Prudic, J, Devanand, DP, Nobler, MS, Lisanby, SH, Peyser, S, Fitzsimons, L, Moody, BJ, Clark, J (2000). A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Archives of General Psychiatry 57, 425–434.Google Scholar
Sackeim, HA, Prudic, J, Nobler, MS, Fitzsimons, L, Lisanby, SH, Payne, N, Berman, RM, Brakemeier, E-L, Perera, T, Devanand, DP (2008). Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimulation 1, 71–83.Google Scholar
Semkovska, M, Keane, D, Babalola, O, McLoughlin, DM (2011). Unilateral brief-pulse electroconvulsive therapy and cognition: effects of electrode placement, stimulus dosage and time. Journal of Psychiatric Research 45, 770–780.Google Scholar
Semkovska, M, Landau, S, Dunne, R, Kolshus, E, Kavanagh, A, Jelovac, A, Noone, M, Carton, M, Lambe, S, McHugh, C, McLoughlin, DM (2016). Bitemporal versus high-dose unilateral twice-weekly electroconvulsive therapy for depression (EFFECT-Dep): a pragmatic, randomized, non-inferiority trial. American Jouranl of Psychiatry 173, 408–417.Google Scholar
Semkovska, M, McLoughlin, DM (2010). Objective cognitive performance associated with electroconvulsive therapy for depression: a systematic review and meta-analysis. Biological Psychiatry 68, 568–577.Google Scholar
Semkovska, M, McLoughlin, DM (2013). Measuring retrograde autobiographical amnesia following electroconvulsive therapy: historical perspective and current issues. Journal of ECT 29, 127–133.Google Scholar
Sobin, C, Sackeim, HA, Prudic, J, Devanand, DP, Moody, BJ, McElhiney, MC (1995). Predictors of retrograde amnesia following ECT. American Journal of Psychiatry 152, 995–1001.Google Scholar
Spaans, HP, Kho, KH, Verwijk, E, Kok, RM, Stek, ML (2013). Efficacy of ultrabrief pulse electroconvulsive therapy for depression: a systematic review. Journal of Affective Disorders 150, 720–726.Google Scholar
Spreen, O, Strauss, E (1998). A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary. Oxford University Press: New York.Google Scholar
Squire, LR, Zouzounis, JA (1986). ECT and memory: brief pulse versus sine wave. American Journal of Psychiatry 143, 596–601.Google Scholar
Swartz, CM, Larson, G (1989). ECT stimulus duration and its efficacy. Annals of Clinical Psychiatry 1, 147–152.Google Scholar
Tew, JD Jr., Mulsant, BH, Haskett, RF, Dolata, D, Hixson, L, Mann, JJ (2002). A randomized comparison of high-charge right unilateral electroconvulsive therapy and bilateral electroconvulsive therapy in older depressed patients who failed to respond to 5 to 8 moderate-charge right unilateral treatments. Journal of Clinical Psychiatry 63, 1102–1105.Google Scholar
Thompson, SG, Higgins, JP (2002). How should meta-regression analyses be undertaken and interpreted? Statistics in Medicine 21, 1559–1573.CrossRefGoogle ScholarPubMed
Tor, PC, Bautovich, A, Wang, MJ, Martin, D, Harvey, SB, Loo, C (2015). A systematic review and meta-analysis of brief versus ultrabrief right unilateral electroconvulsive therapy for depression. Journal of Clinical Psychiatry 76, e1092–e1098.Google Scholar
UK ECT Review Group (2003). Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 361, 799–808.Google Scholar
Van der Linden, M, GREMEM (2004). L’évaluation des troubles de la mémoire: présentation de quatre tests de mémoire épisodique (avec leur étalonnage). Solal: Marseille.Google Scholar
Vos, T, et al. (2012). Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 380, 2163–2196.Google Scholar
Supplementary material: File

Kolshus supplementary material

Figures S1-S4

Download Kolshus supplementary material(File)
File 424.6 KB