Unilateral v bilateral: ECT in the LA Times

Last week the Los Angeles Times ran a story about electroconvulsive therapy (ECT). There were a couple of quotes from members of the panel which recently voted to advise the Food and Drug Administration (FDA) to keep ECT machines in the high risk category when treating depression. Professor Mae Gordon for example was quoted as expressing concern about the lack of data on long-term efficacy and safety of ECT.

But the main theme of the article was the familiar one of “old v new”. The article makes the astonishing claim that bilateral ECT is no longer used:

“In today’s version of ECT, an electrical current is applied to one side of the head… To reduce chances of memory loss, it’s no longer administered to both sides of the brain”.

In fact, according to the most recent statistics (which admittedly aren’t very recent, dating back over ten years) most Americans who undergo ECT have the old-fashioned, original, bilateral treatment.  A survey of 59 ECT clinics in the New York area in 1997 found that 75 per cent of patients underwent bilateral, rather than unilateral, ECT. In 34 clinics over 90 per cent of patients were given bilateral. And statistics from Texas in the 1990s show an even lower proportion of patients receiving unilateral. Has there been a significant change in practice since these surveys were carried out? I think if psychiatrists had defected en masse from bilateral, we would have seen something about somewhere.

There are some countries where more recent statistics about electrode placement are available. In Scotland in 2009 93 per cent of courses involved bilateral ECT; 14 per cent unilateral, with overlap in 10 per cent. This was a small increase in the use of unilateral compared to 2006, when 9 per cent of courses involved unilateral.  Unilateral ECT is not new – it has been around for over 50 years, and the trend is not always in the direction of greater use of unilateral. A survey of ECT practice in Great Britain in 1980 found that 21 per cent of courses were unilateral; a survey of 50 clinics in England and Wales in the mid 90s found only 7 per cent of ECT patients receiving unilateral. The authors of the earlier survey had this to say about psychiatrists’ views on bilateral v unilateral:

“Unilateral ECT is used rarely or never in 80 per cent of clinics. It has been reported thaat unilateral ECT causes less confusion and memory disturbance and is as effective a treatment as bilateral ECT at least for depressive illness. Two main reasons were repeatedly given to us during the visits for preferring bilateral ECT; it is easier to give and fewer treatments are needed. However, we saw many giving it using faulty techniques. In the few clinics visited where unilateral ECT is routinely used it was given skilfully. We saw that patients are more alert after treatment and records do not indicate that courses are unduly long or that relapse occurs more quickly”.

In Australia, unilateral ECT is used more extensively – two-thirds of treatments are unilateral according to one survey, although this survey did not say how many people who received unilateral were later switched to bilateral.

PS. At a later date the LA Times added a correction:

“FOR THE RECORD – An online article published March 19 about an FDA review of the risks of electroshock therapy incorrectly reported that the procedure — now known as electroconvulsive therapy, or ECT — is no longer administered to both sides of the brain to reduce the chances of memory loss. ECT is, in fact, still sometimes administered bilaterally.”

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