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Randomized comparison of ultra-brief bifrontal and unilateral electroconvulsive therapy for major depression: Clinical efficacy
Journal of Affective Disorders, 06/11/09

Sienaert P et al. - Using an ultra-brief pulse width, both BF and UL-ECT are efficacious, although patients receiving UL-ECT achieve response/remission-criteria after a smaller number of treatments.

Methods

Eighty-one patients with a medication refractory depressive episode were treated with a course of bifrontal ultra-brief pulse ECT at 1.5 times seizure threshold or unilateral ultra-brief pulse ECT at 6 times seizure threshold by random assignment.
The 17 item-Hamilton Rating Scale for Depression (HRSD), Beck Depression Inventory, Clinical Global Impression and Patient Global Impression were administered at baseline and repeated weekly during and 1 and 6 weeks after the course, by a blinded rater.

Results

64/81 patients (79%) completed the study, half of which were treated with bifrontal ECT.
At the end of the course, 78.1% of the BF group and 78.1% of the UL group responded, whereas, 34.38% (N = 11) of the BF group and 43.75% (N = 14) of the UL group achieved strict remission criteria (HRSD-score ? 7).
There were no significant differences between the patients given bifrontal ECT and those given unilateral ECT, although patients receiving unilateral ECT achieved response/remission-criteria after a smaller number of treatments.

Exclusive Author Commentary
pascal sienaert, 06/12/09

Sackeim and co-workers (2008) found UB bitemporal ECT to have markedly inferior antidepressant efficacy compared to UB RUL ECT (remission rates 35% and 73%, respectively), and concluded that bilateral ECT administered with an UB stimulus lacks efficacy. Our results show that this observation does not apply to UB bifrontal ECT, as the response/remission rates after UB BF ECT and UB RUL ECT are comparable. The response rates of the BF-group in our study were not lower than these of the RUL-group (78% in both groups), whereas in the Sackeim et al.-study, the difference between BT and RUL response rates were marked. The low response rates of the BT-group in the Sackeim et al.-study, at odds with the superior rate of the BF-group in our study, is surprising (Kellner, 2009), since it has been shown that both bilateral techniques, when administered with a standard pulse stimulus and an equal stimulus dose, have comparable antidepressant efficacy (Bailine et al., 2000; Ranjkesh et al., 2005; Letemendia et al., 1993). The differences in response rates in the two studies are even more puzzling, because in our study, the dosage used in the BF-group (1.5 times the initial ST) was lower (thus expected to be less efficacious) than the dosage used in the BT-group in the Sackeim et al.-study (2.5 times ST). It is unclear to what extent the pulse width used can explain these differences in efficacy. In our study, UB RUL ECT has, however, an advantage over UB BF ECT, when speed of response is concerned. Patients treated with RUL ECT meet response criteria after a significantly lower number of treatment sessions (7.8 versus 10.1). Moreover, at each point in time, the estimated odds of achieving response and remission criteria are higher for patients receiving RUL ECT, as compared to patients receiving BF ECT. Comparable results have been reported in a standard pulse (1.0 ms) ECT-study by Heikman and co-workers (2002): high dose RUL ECT yielded a faster antidepressant effect than low dose BF ECT. In this study the low dosage, i.e. a stimulus at ST, can explain the inferior outcome of BF ECT. In our study, adequate stimulus doses were used, so this cannot account for the difference in speed of response. It remains unclear whether the difference in speed of response is associated with electrode position or with an interaction of electrode position and pulse width. The results of other studies yield conflicting results. As discussed before, our results show that the use of UB ECT requires a higher number of treatments than the number reported in studies with standard pulse ECT. This is in line with the results of the Loo et al.-study (2007, 2008): patients remitting after UB RUL ECT had more treatments (11.8) than those remitting after standard pulse RUL ECT (8.8); and part of the results of the Sackeim et al.- study (2008): patients remitting after UB BT ECT had more treatments (8.9) than those remitting after standard pulse BT ECT (6.2). In contrast with these data, the number of treatments in the UB RUL-group of the Sackeim et al.-study (2008) (8.9) did not differ from the standard pulse RUL-group (8.5). With a total of fewer than 200 patients reported on in the 3 published trials (i.e. this study, Sackeim et al., and Loo et al.), it is difficult to draw definite conclusions. It seems, however, that the choice of an UB pulse width is reasonable with RUL ECT, perhaps with BF ECT and perhaps not with BT ECT, and that it is possible that UB ECT needs more treatments than standard pulse ECT to exert its full antidepressive efficacy. Interestingly, data on standard pulse ECT show a different pattern. In the yet unpublished ‘3 electrode positions-study’ of the Consortium for Research on ECT, 230 patients with a depressive episode were randomized to BT (N=72), BF (N=81) or RUL (N=77) ECT, using a 1 ms-pulse width. There was a slight though non-significant advantage in efficacy for BT, over RUL, with BF somewhere in between (response rates BT 81.9%; BF: 79%; RUL: 72.7%; remission rates BT: 63.9%; BF: 60.5; RUL: 54.6%) (Kellner, 2009a).

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