In my last post I mentioned a study published nearly fifty years ago, in 1968, in the British Journal of Psychiatry (M. Valentine, K.M.G. Keddie and D. Dunne, “A comparison of techniques in electro-convulsive therapy”). The authors concluded that unilateral ECT (both electrodes on one side of the head) was as effective as bilateral (electrodes on either side of the head) and caused fewer side-effects.
Recently a study was carried out on patients undergoing ECT at St Patrick’s Hospital, Dublin, Ireland, and the same conclusions were reached. The research was presented in the media as something new. The Irish Medical Times said
“New research from Trinity College Dublin has suggested that changing the position on the head of the electrodes used in electroconvulsive therapy (ECT) could reduce memory side-effects, whilst maintaining the effectiveness of the treatment for those with severe depression.”
While the Irish Times said:
“[N]ew research carried out at St Patrick’s University Hospital in Dublin has found that by modifying ECT, memory side-effects can be reduced while maintaining the therapy’s effectiveness. Professor of psychiatry at Trinity College Declan McLoughlin, who led the research, published in the American Journal of Psychiatry, found that by altering the position of the electrodes on a patient’s head when carrying out the therapy, side-effects to the brain could be reduced.”
Neither article mentioned that unilateral ECT dates from the 1950s and that there have been numerous studies comparing it to bilateral ECT. Nor did they ask why, since most studies have found similar results (unilateral as effective as bilateral with fewer side-effects), bilateral has remained the most widely used form of treatment.
The research in question is published ahead of print in the American Journal of Psychiatry: “Bitemporal Versus High-Dose Unilateral Twice-Weekly Electroconvulsive Therapy for Depression (EFFECT-Dep): A Pragmatic, Randomized, Non-Inferiority Trial” by M. Semkovska et al. (ten of them). The authors conclude:
“Our study has important clinical implications. In terms of harms/benefits ratio, high-dose unilateral ECT was noninferior to bitemporal ECT but showed a better cognitive profile, especially for preserving retrograde personal memories and fewer subjective cognitive side effects.”
Whether it will have any more impact on clinical practice than all the other bilateral v unilateral studies remains to be seen. In a survey of ECT practice in the Republic of Ireland in 1982 it was found that 80 per cent of ECT was bilateral. I don’t know how that compares to current practice as I have been unable to find any recent figures. In Great Britain in 1981, 22 per cent of ECT courses were unilateral and that percentage, in Scotland at least, has gone down considerably. What, in the years since the 1968 study, have the psychiatric leadership had to say?
In 1977 the Royal College of Psychiatrists’ memorandum on ECT admitted to some doubts: “Whether unilateral or bilateral ECT is more effective, and if so under what circumstances is still uncertain”. By 1989 they had decided that, with brief pulse machines, unilateral was less effective than bilateral but should still be considered where minimizing side-effects was important. In 1995 they were saying much the same but added:
“Many patients respond to UECT and there are claims that high-energy BECT is as effective as BECT while still having fewer side-effects. There is urgent need for further studies comparing BECT and high-energy UECT”.
The American Journal of Psychiatry article also appeared to contain what is a very rare admission of persistent memory loss:
“Bitemporal ECT was associated with a lower percent recall of autobiographical information (odds ratio=0.66) that persisted for 6 months.”
The very lowest recall consistency score at 6 months belonged however to someone who had had unilateral treatment.
An interesting difference between the results of the 1968 and 2015 studies was in the time taken for the patients to recover orientation. In 2015 the median time was 19.1 minutes for the unilateral group and 26.4 minutes for the bilateral group (both groups received brief-pulse ECT). In 1968 it was two and a half minutes for the unilateral brief-pulse group and 8 minutes for the bilateral group. In fact the differences are even greater because in 1968 the measurements were taken from the time of the electric shock, while in 2015 they were taken from the time of the recovery of spontaneous breathing. Was perhaps the electric shock used in 1968 less powerful than that used in 2015? Unfortunately the 1968 authors didn’t include information on amount of electrical charge.
In other news about ECT from the Republic of Ireland: the latest report from the Mental Health Commission, published in November 2015, showed that in 2013 in Ireland 318 courses of ECT were given to 257 people, a rise of about 2 per cent over the previous year.
The number of people treated without their consent rose from 27 in 2012 to 46 in 2013. Thirty-nine of them were considered to lack capacity, one was considered by both the treating psychiatrist and the other psychiatrist called in to authorise the treatment to have capacity but to be unwilling to have ECT, and for the others there was disagreement between the two psychiatrists over whether they were incapable or unwilling. (In February 2016 an amendment to the law came into force so that people can only be given ECT without their consent if they are deemed to lack capacity.)
Patients ranged in age from 18 to 93, with an average of 60 years. Women accounted for 63 per cent of those receiving ECT. The report says: “The percentage of females is reflective of a greater proportion of women (56%) admitted to approved centres with a primary diagnosis of depressive disorders in 2013.” However 56/44 is not quite the same as 63/37.
St Patrick’s University Hospital accounted for nearly 40 per cent of ECT courses.
At nearly two years from the end of the reporting period, it takes the Irish Mental Health Commission twice as long to bring out a report on ECT use as it does the Scottish ECT Accreditation Network.