Skip to main content
×
×
Home

Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial

  • Charles H. Kellner (a1), Rebecca Knapp (a2), Mustafa M. Husain (a3), Keith Rasmussen (a4), Shirlene Sampson (a4), Munro Cullum (a3), Shawn M. McClintock (a3), Kristen G. Tobias (a1), Celena Martino (a5), Martina Mueller (a2), Samuel H. Bailine (a6), Max Fink (a7) and Georgios Petrides (a8)...
Abstract
Background

Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements.

Aims

To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT.

Method

This multicentre randomised, double-blind, controlled trial (NCT00069407) was carried out from 2001 to 2006. A total of 230 individuals with major depression, bipolar and unipolar, were randomly assigned to one of three electrode placements during a course of ECT: bifrontal at one and a half times seizure threshold, bitemporal at one and a half times seizure threshold and right unilateral at six times seizure threshold.

Results

All three electrode placements resulted in both clinically and statistically significant antidepressant outcomes. Remission rates were 55% (95% CI 43–66%) with right unilateral, 61% with bifrontal (95% CI 50–71%) and 64% (95% CI 53–75%) with bitemporal. Bitemporal resulted in a more rapid decline in symptom ratings over the early course of treatment. Cognitive data revealed few differences between the electrode placements on a variety of neuropsychological instruments.

Conclusions

Each electrode placement is a very effective antidepressant treatment when given with appropriate electrical dosing. Bitemporal leads to more rapid symptom reduction and should be considered the preferred placement for urgent clinical situations. The cognitive profile of bifrontal is not substantially different from that of bitemporal.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial
      Available formats
      ×
Copyright
Corresponding author
Charles H. Kellner, MD, Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, Box 1230, New York, NY 10029, USA. Email: charles.kellner@mssm.edu
Footnotes
Hide All

See editorial, pp. 171–172, this issue.

C.H.K. research support from the National Institute of Mental Health (NIMH), loan of ECT device from Somatics LLC (no monies involved). M.M.H. research support from the NIMH, Stanley Medical Research Institute, Cyberonics, Inc, Magstim, Neuronetics and Advanced Neuromodulations Systems (ANS). S.M.M., K.G.T and C.M. research support from the NIMH. G.P. research support from AstraZeneca, Novartis, Corcept, NIMH. This study was supported by the NIMH (NCT00069407).

Declaration of interest

M.M.H. speakers bureau honoraria from AstraZeneca, BMS and Forest Lab.

Footnotes
References
Hide All
1 Friedman, E. Unidirectional electrostimulated convulsive therapy. I: The effect of wave form and stimulus characteristics on the convulsive dose. Am J Psychiatry 1942; 99: 218–23.
2 Lancaster neuropsychological, Steinert RR, Frost I. Unilateral electroconvulsive therapy. J Ment Sci 1958; 104: 221–7.
3 Fink, M. Convulsive Therapy: Theory and Practice. Raven Press Books, 1979.
4 D'Elia, G, Frederiksen, SO, Raotma, H, Widepalm, K. Comparison of fronto-frontal and temporo-parietal unilateral ECT. Acta Psychiatr Scand 1977; 56: 233–9.
5 American Psychiatric Association. Task Force on Electroconvulsive Therapy. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging. APA, 2001.
6 Abrams, R. Electroconvulsive Therapy (4th edn). Oxford University Press, 2002.
7 Fink, M, Taylor, MA. Electroconvulsive therapy: evidence and challenges. JAMA 2007; 298: 330–2.
8 Letemendia, FJ, Delva, NJ, Rodenburg, M, Lawson, JS, Inglis, J, Waldron, JJ, et al. Therapeutic advantage of bifrontal electrode placement in ECT. Psychol Med 1993; 23: 349–60.
9 Sackeim, HA, Prudic, J, Devanand, DP, Nobler, MS, Lisanby, SH, Peyser, S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000; 57: 425–34.
10 Sackeim, HA, Prudic, J, Devanand, DP, Kiersky, JE, Fitzsimons, L, Moody, BJ, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993; 328: 839–46.
11 Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis. Lancet 2003; 361: 799808.
12 McCall, WV, Reboussin, DM, Weiner, RD, Sackeim, HA. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy: acute antidepressant and cognitive effects. Arch Gen Psychiatry 2000; 57: 438–44.
13 Bailine, SH, Rifkin, A, Kayne, E, Selzer, JA, Vital-Herne, J, Blieka, M, et al. Comparison of bifrontal and bitemporal ECT for major depression. Am J Psychiatry 2000; 157: 121–3.
14 Sackeim, HA. Memory and ECT: from polarization to reconciliation. J ECT 2000; 16: 8796.
15 Fink, M. Electroshock: Restoring the Mind. Oxford University, 1999.
16 Shorter, E, Healy, D. Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness. Rutgers University Press, 2007.
17 Prudic, J. Strategies to minimize cognitive side effects with ECT: aspects of ECT technique. J ECT 2008; 24: 4651.
18 Petrides, G, Fink, M, Husain, MM, Knapp, RG, Rush, AJ, Mueller, M, et al. ECT remission rates in psychotic versus nonpsychotic depressed patients: a report from CORE. J ECT 2001; 17: 244–53.
19 Kellner, CH, Knapp, RG, Petrides, G, Rummans, TA, Husain, MM, Rasmussen, K, et al. Continuation electroconvulsive therapy vs pharmacotherapy for relapse prevention in major depression: a multisite study from the Consortium for Research in Electroconvulsive Therapy (CORE). Arch Gen Psychiatry 2006; 63: 1337–44.
20 First, MB, Spitzer, RL, Gibbon, M, Williams, JBW. Structured Clinical Interview for Axis I DSM–IV Disorders – Patient Edition (SCID–I/P, Version 2.0). Biometrics Research Department, 1995.
21 Hamilton, M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23: 5662.
22 Folstein, MF, Folstein, SE, McHugh, PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. J Psychiatric Res 1975; 12: 189–98.
23 d'Elia, G. Unilateral electroconvulsive therapy. Acta Psychiatr Scand Suppl 1970; 215: 198.
24 Rey, A. L'Examen Clinique en Psychologie. Press Universitaire de France, 1964.
25 Schmidt, M. Rey Auditory Verbal Learning Test: A Handbook. Western Psychological Services, 1996.
26 Taylor, LB. Localisation of cerebral lesions by psychological testing. Clin Neurosurg 1969; 16: 269–87.
27 Rey, A, Osterrieth, PA. Translations of excerpts from Andre Rey's ‘Psychological examination of traumatic encephalopathy’ and PA Osterrieth's ‘The complex figure test’ (J Corwin, FW Bylsma, trans). Clin Neuropsychol 1993; 7: 321.
28 Sackeim, HA, Prudic, J, Devanand, DP, Kiersky, JF, Fitzsimons, L, Moody, BJ, et al. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. New Engl J Med 1993; 328: 839–46.
29 Reitan, RM. Trail Making Test. Reitan Neuropsychological Laboratory, 1979.
30 Benton, AL, Hamsher, K. Multilingual Aphasia Examination. AJA Associates, 1983.
31 Stroop, JR. Studies of interference in serial verbal reaction. J Exp Psychol 1935; 18: 643–62.
32 Golden, CJ, Freshwater, SM. The Stroop Color and Word Test: A Manual for Clinical and Experimental Uses. Stoelting Co, 2002.
33 Strauss, E, Sherman, EMS, Spreen, O. A Compendium of Neuropsychological Tests: Administration, Norms, and Commentary. Oxford University Press, 2006.
34 Delis, DC, Kaplan, E, Kramer, J. The D–KEFS Sorting Test. The Psychological Corporation, 2001.
35 Wilkinson, GS. Wide Range Achievement Test (WRAT-3) Administration Manual. Wide Range Inc, 1993.
36 Sobin, C, Sackeim, HA, Prudic, J, Devanand, DP, Moody, BJ, McElhlney, MC. Predictors of retrograde amnesia following ECT. Am J Psychiatry 1995; 152: 9951001.
37 Guy, W. ECDEU Assessment Manual for Psychopharmacology. Superintendent of Documents, US Government Printing Office, US Department of Health, Education and Welfare Publication, 1976.
38 Hedeker, D, Gibbons, RD. Longitudinal Data Analysis. John Wiley and Sons, 2006.
39 Sackeim, HA, Prudic, J, Nobler, MS, Fitzsimons, L, Lisanby, SH, Payne, N, et al. Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stim 2008; 1: 7183.
40 Lisanby, SH, Devanand, DP, Nobler, MS, Prudic, J, Mullen, L, Sackeim, HA. Exceptionally high seizure threshold: ECT device limitations. Convuls Ther 1996; 12: 156–64.
41 Keisling, R. Successful treatment of an unidentified patient with one ECT. Am J Psychiatry 1984; 141: 148.
42 Rich, CL. Recovery from depression after one ECT. Am J Psychiatry 1984; 141: 1010–1.
43 Thomas, SG, Kellner, CH. Remission of major depression and obsessive-compulsive disorder after a single unilateral ECT. J ECT 2003; 19: 50–1.
44 McCall, WV, Dunn, A, Rosenquist, PB, Hughes, D. Markedly suprathreshold right unilateral ECT versus minimally suprathreshold bilateral ECT: antidepressant and memory effects. J ECT 2002; 18: 126–9.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 11
Total number of PDF views: 112 *
Loading metrics...

Abstract views

Total abstract views: 539 *
Loading metrics...

* Views captured on Cambridge Core between 2nd January 2018 - 16th August 2018. This data will be updated every 24 hours.

Bifrontal, bitemporal and right unilateral electrode placement in ECT: randomised trial

  • Charles H. Kellner (a1), Rebecca Knapp (a2), Mustafa M. Husain (a3), Keith Rasmussen (a4), Shirlene Sampson (a4), Munro Cullum (a3), Shawn M. McClintock (a3), Kristen G. Tobias (a1), Celena Martino (a5), Martina Mueller (a2), Samuel H. Bailine (a6), Max Fink (a7) and Georgios Petrides (a8)...
Submit a response

eLetters

Re: �Bifrontal ECT: Is the evidence good enough to abandon its practice?�

Max Fink, Neuropsychiatrist
14 July 2010

July 5, 2010

Move On! End the Obsession with Electrode Placement in ECT

To the Editor,

For more than half-century researchers have been pre-occupied with electrode placement in inducing seizures in electroconvulsive therapy, seeking to diminish the usually transient confusional syndrome. Early in the ECT era studies of different placements had found non-dominant placement (RUL) to diminish the immediate cognitive impact of seizures but at the price of diminished clinical efficacy in lower remission rates and requiring more treatments for an effective clinical outcome.(1) The differences are best seen as diminished physiologic effects demonstrated in lesser degrees of EEG slowing (2) and lesser release of prolactin from centrencephalic stores to

blood.(3,4) By 1980, bilateral electrode placement (BL) had become the accepted principal method of ECT seizure induction. (5,6)

In the late 1980s, interest in reducing cognitive effects resurfaced with public outcries that ECT was a brain damaging procedure.(7) Two NIMH supported studies examined electrode placement, electrical energy dosing, and cognition.(8,9) "Measuring" seizure threshold (ST) was introduced with

assertions that minimizing energy dosing and unilateral electrode placement would reduce the impact on cognition. Indeed, RUL placement at dosing of 1.5xST and 2.5xST significantly reduced the impact on immediate cognitive tests but with lesser clinical efficacy. (10,11) To achieve equivalence to BL placement, however, dosing greater than 6xST was necessary, at which time the advantage in lesser cognitive effects was lost.(12)

Two studies of continuation treatments to sustain the benefits of ECTin patients with unipolar major depression were launched, one electing to deliver seizures through RUL placement at 2.5x ST (13) and the second with

BL placement at 1.5xST.(14) The results are definitive. The remission rate for RUL was 55%, for BL 84%, requiring an average of 10.5 treatments for RUL and 7.3 for BL, without measurable advantages in cognitive measures.(15)

Canadian investigators then renewed interest in bifrontal (BF) electrode placement anticipating lesser immediate cognitive effects. (16) The CORE group undertook a proper RCT comparison of the BL, BF, and RUL electrode placements at optimized dosing. The findings are again definitive.(17, 18)

The efficacy and cognitive effects of the three placements are indistinguishable. From this vantage RUL placement loses merit -- it is more difficult to position electrodes properly; it requires special attention to energy dosing; and when dosing is based on seizure threshold determination, inadequacy of the first treatment and additional cardiac risks are guaranteed. (Nor is an advantage for BF demonstrated.)

Unfortunately the CORE electrode study did not include physiological measures, as neither the seizure nor the interseizure EEG was recorded, nor were blood prolactin and other peptide levels at appropriate post-seizure time intervals measured. Such studies are of immediate interest.

Electrode placement is a technical choice that is not critical to the

outcome of ECT. The efficiency of BL makes it the gold standard for effective treatment. It is time to end the charade of interest in electrode placement or electrical energy parameters and move on to understanding of the role of seizure physiology in treatment efficacy.__________________1. Abrams R, Fink M, Dornbush R, et al. Unilateral and bilateral ECT: effects on depression, memory and electroencephalogram. Arch Gen Psychiatry 1972; 27:88-91.

2. Volavka J, Feldstein S, Abrams R, Fink M. EEG and clinical changeafter bilateral and unilateral electroconvulsive therapy. Electroencephalogr clin Neurophysiol 1972; 32:631-9.

3. Abrams R, Swartz CM. ECT and prolactin release: effects of stimulus parameters. Convuls Ther 1985; 1: 115-9.

4. McCall WV, Weiner RD, Carroll BJ et al. Serum prolactin, electrode

placement, and the convulsive threshold during ECT. Convuls Ther 1996; 12:81-5.

5. American Psychiatric Association. Electroconvulsive Therapy. Task Force Report #22. Washington DC: American Psychiatric Association, 1978.

6. Fink M. Convulsive Therapy: Theory and Practice. New York: Raven Press, 1979.

7. Shorter E, Healy D. Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness. Piscataway NJ: Rutgers University Press, 2006.

8. Weiner RD, Rogers HJ, Davidson JRT et al. Effects of stimulus parameters on cognitive side effects. Ann N.Y. Acad Sci 1986; 462:315-25.

9. Sackeim HA, Decina P, Kanzler M et al. Effects of electrode placement on efficacy of titrated, low dosage ECT. Am J Psychiatry 1987; 144:1449-1455.

10. Sackeim HA, Decina P, Portnoy S et al. Studies of dosage, seizure

threshold, and seizure duration in ECT. Biol Psychiatry 1987; 22:249-68.

11. Sackeim HA, Decina P, Prohovnik J, Malitz S. Seizure threshold in

electroconvulsive therapy: effects of sex, age, electrode placement, and number of treatments. Arch Gen Psychiatry 1987; 44:355-60.

12. McCall WV, Reboussin DM, Weiner RD et al. Titrated moderately suprathreshold vs fixed high-dose right unilateral electroconvulsive therapy. Arch Gen Psychiatry 2000; 57:438-44.

13. Sackeim HA, Haskett RF, Mulsant BH et al. Continuation pharmacotherapy in the prevention of relapse following electroconvulsive therapy. JAMA 2001; 285:1299-307. JAMA 2001.

14. Kellner CH, Knapp RG, Petrides G et al. Continuation ECT versus pharmacotherapy for relapse prevention in major depression: a multi-site study from CORE. Archives General Psychiatry . 2006; 63:1337-44.

15. Fink M, Taylor MA. Electroconvulsive therapy: Evidence and challenges. JAMA 2007; 298: 330-332.

16. Letemendia JF, Delva NJ, Rodenberg M et al. Therapeutic advantageof bifrontal electrode placement in ECT. Psychol Med 1993; 23:349-60.

17. Kellner CH, Knapp R, Husain MM, et al. Bifrontal, bitemporal andright unilateral electrode placement in ECT: randomized trial. Br J Psychiatry 2010; 196: 226-34.

18. Bailine SH, Fink M, Knapp R, et al. ECT is equally effective inunipolar and bipolar depression. Acta Psychiatr Scand 2010;121:431-436.
... More

Conflict of interest: None Declared

Write a reply

Re: �Bifrontal ECT: Is the evidence good enough to abandon its practice?�

Charles H. Kellner, Professor
14 July 2010

We appreciate Dr. Gangadhar and colleagues’ comments about our study1; however, wedisagree with their conclusions. We were circumspect in interpreting our data and emphasized the excellent efficacy of all three electrode placements.

Dr. Scott2 took the conclusions a bit further than we did. Gangadhar et al. state that our findings are “in contrast” with several earlier studies and offer the review by Plakiotis3 et al. as evidence. That review concluded, “The literature regarding bifrontal ECT is limited,with small patient numbers and treatment variation across studies complicating result interpretation… while bifrontal and bitemporal ECT mayhave similar efficacy, bifrontal ECT is associated with less cognitive impairment immediately after a treatment course. Bifrontal ECT may have greater efficacy than low-dose right unilateral ECT but less efficacy thanhigh-dose right unilateral ECT… detailed cognitive testing should be undertaken as part of any future, large scale studies comparing the efficacy of adequately-dosed bifrontal, bitemporal and right unilateral ECT.” Our study is the largest reported comparison of the three electrode placements and included a comprehensive neurocognitive assessment battery.Gangadhar et al. question the diagnostic indications for ECT in our study patients. The indications for ECT in our study were standard for any ECT study of major depression; this was a severely ill cohort of carefully diagnosed patients with a mean HAMD24 score of 34.6. It is highly unlikely that diagnostic differences either between our study and others, or between our three study treatment groups, were responsible for our outcomes.Gangadhar et al. further commented that, “patients in all three groups achieved remission with much fewer ECTs than in other studies.” We reported the number of ECT for remitters in each group; the two Sackeim studies4,5 they cited reported a higher number of ECT ( 9-10, as opposed to 6), but those figures were for all study participants, not just remitters. They suggested that a greater number of ECT in the bifrontal group might explain the lack of superior cognitive outcome in this group. Patients in the bifrontal group received, on average, a slightly higher number of ECT, and this may have affected their cognitive performance. However, contrary to the authors’ statement that the number of ECT “shouldbe used as a covariate in multivariate analyses,” adjustment of a “downstream” variable that is potentially in the causal pathway is inappropriate and can lead to a biased comparison. Overall, we were careful to note the limitations of our neurocognitive data. Gangadhar et al. conclude that “the study by Kellner et al does not provide strong evidence against BFECT.” That is true, but a more even handed description of our findings is that we found no particular superiority of bifrontal placement in efficacy or cognition. We plan continued analyses of our dataset and invite other investigators to contribute to the database documenting the relative antidepressant efficacy and tolerability of different electrode placements in ECT.

References

1. Kellner CH, Knapp R, Husain MM, Rasmussen K, Sampson S, Cullum M, et al. Bifrontal. Bitemporal and right unilateral electrode placement in ECT: randomized trial. Br J Psychiatry 2010; 196: 226-34.

2. Scott AI. Electroconvulsive therapy, practice and evidence. Br J Psychiatry 2010; 196: 171-2.

3. Plakiotis C, O’Connor D. Bifrontal ECT: A systematic review and meta- analysis of efficacy and cognitive impact. Current Psychiatry Reviews 2009; 5: 202-17.

4. Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000; 57: 425-34.

5. Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, MoodyBJ, et al. Effects of stimulus intensities and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993; 328: 839-46
... More

Conflict of interest: None Declared

Write a reply

�Bifrontal ECT: Is the evidence good enough to abandon its practice?�

Bangalore N Gangadhar, Professor of Psychiatry,
02 June 2010

We read with interest the study comparing the bifrontal, bitemporal and right unilateral electrode placements for electroconvulsive therapy (ECT) in patients with depression 1 and the accompanying editorial 2. The study has concluded that patients receiving bitemporal ECT make faster recovery from depression while experiencing fewer cognitive adverse effects than those receiving bifrontal ECT. This is in contrast to severalearlier studies, which have found that bifrontal ECT is at least as efficacious as, if not more than, bitemporal ECT; cognitive advantages of bifrontal ECT over bitemporal ECT have also been consistently found. Thesestudies were included in a recent systematic review 3 and the analysis of the pooled data showed these findings to be consistent. The study by Kellner et al 1 is the first study to have concluded that bitemporal ECT is superior to bifrontal ECT both in efficacy and cognitive effects. No previous study in depression had found the bifrontal ECT was inferior to bitemporal ECT in either efficacy or cognitive effects. How do the authorsexplain their contrasting findings? Moreover, we have found that bifrontalECT is superior to bitemporal ECT in other indications as well: acute mania 4 and schizophrenia (Phutane et al, paper in preparation). Authors could have discussed the discrepant findings, considering that they were the first to refute the findings of superiority of BFECT. Interestingly, the editorial too interprets the findings of this study as suggesting thatthere is ‘no justification for the use of bifrontal ECT’. We found that important details are lacking in this recent article by Kellner et al 1. The indications for ECT in their study were typically, “…multiple failed medication trials and severity/urgency of illness”. Could the discrepant findings of this study due to an uneven distribution of patients with either indication across the three ECT groups? In this study, patients in all three groups achieved remission status with much fewer ECTs than in other studies, which too have used similar criteria 5, 6. How do authors explain this? Cognitive performance assessed at the end of ECT course is influenced by the number of ECT sessions – with each additional ECT, cognitive impairments increase. This should be used as covariate in multivariate analyses. This is particularly important in thisstudy, as there was a difference in the rate of improvement across the three groups - bifrontal ECT patients may have received more ECTs and thiscould have reflected in the differential performance in the cognitive assessments. The authors could have provided the details about the number of ECTs received by patients across the three groups. Finally, the resultsof the analysis of the cognitive functions should be considered cautiously, by authors own admission, as nearly half of the data had to beimputed because of missing values. Bifrontal ECT has shown promise in balancing efficacy and adverse effects.Unless there is strong evidence against this, it would be premature to disband its practice. In the light of the above points, we believe that the study by Kellner et al 1 does not provide strong evidence against BFECT.

References:1.Kellner CH, Knapp R, Husain MM, Rasmussen K, Sampson S, Cullum M, et al. Bifrontal. Bitemporal and right unilateral electrode placement in ECT:randomized trial. Br J Psychiatry 2010; 196: 226-34.2.Scott AI. Electroconvulsive therapy, practice and evidence. Br J Psychiatry 2010; 196: 171-2.3.Plakiotis C, O’Connor D. Bifrontal ECT: A systematic review and meta-analysis of efficacy and cognitive impact. Current Psychiatry Reviews 2009; 5: 202-17.4.Hiremani RM, Thirthalli J, Tharayil BS, Gangadhar BN. Double-blind randomized controlled study comparing short-term efficacy of bifrontal andbitemporal electroconvulsive therapy in acute mania. Bipolar Disord 2008; 10: 701-7.5.Sackeim HA, Prudic J, Devanand DP, Nobler MS, Lisanby SH, Peyser S, et al. A prospective, randomized, double-blind comparison of bilateral and right unilateral electroconvulsive therapy at different stimulus intensities. Arch Gen Psychiatry 2000; 57: 425-34.6.Sackeim HA, Prudic J, Devanand DP, Kiersky JE, Fitzsimons L, Moody BJ, et al. Effects of stimulus intensities and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. N Engl J Med 1993; 328: 839-46.
... More

Conflict of interest: None Declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *