Electronic Letters to:
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eLetters: Electronic letters published:
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Unilateral ECT deserves a fair trial
- Vimal Sivasanker (11 March 2009)
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ECT: There is more than just Unilateral or Bilateral selection!
- Dr Mukesh Kripalani, Dr Vinod Chaugule, Consultant Psychiatrist and ECT lead for Tees, Esk and Wear Valley NHS Foundation Trust (1 April 2009)
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Vimal Sivasanker, Consultant, PICU and ECT Bedfordshire and Luton Mental Health and Social Care Partnership NHS Trust
Send letter to journal:
vimal.sivasanker{at}blpt.nhs.uk Vimal Sivasanker
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Brown’s survey on ECT laterality clearly demonstrated the pervasive belief amongst the majority of psychiatrists that bilateral ECT is significantly superior to unilateral ECT in terms of efficacy. It is a great shame that the comparison of laterality by the UK ECT Review Group included sub-therapeutic doses of unilateral ECT as this compounds the problem which has influenced many psychiatrists’ thinking on this issue, namely that their opinions about the inefficacy of unilateral ECT are based on out-of-date studies using suboptimal treatment doses for unilateral ECT. A small, local survey which I conducted amongst consultants in my Trust a couple of years ago revealed that none of the respondents would consider using unilateral ECT as the default treatment laterality for non-life-threatening cases and most would not consider using unilateral ECT at all. Despite trainee and consultant teaching and regular e-mail updates from the ECT department, this view has not substantially changed. It is not surprising that the most important factor for doctors is that their patients get better. Brown’s suggestion that future studies should focus on efficacy and remission rates is a good one. Very few patients I have treated have been suffering from a severe or life- threatening illness episode which warranted the speed of response produced by bilateral ECT, so it would be highly feasible to be able to randomise a large proportion of ECT patients to unilateral or bilateral treatment. A sound evidence base could then be produced from the sort of multicentre trial Brown suggests, with the aid of SEAN and hopefully ECTAS as well. However, if the comparison between unilateral and bilateral ECT is to be fair, ECT prescribers and those administering the treatments must be clear about stimulus dosing and therapeutic dose calculation principles and the appropriate therapeutic doses for unilateral ECT in particular, else we will simply reproduce the misleading results of the past and further hamper evidence-based debate and guidance development about ECT laterality. |
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Dr Mukesh Kripalani, Specialist Registrar Adult Psychiatry Northern Deanery, Dr Vinod Chaugule, Consultant Psychiatrist and ECT lead for Tees, Esk and Wear Valley NHS Foundation Trust
Send letter to journal:
drmukesh{at}doctors.org.uk Dr Mukesh Kripalani, et al.
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The assumption that all doctors are well
informed about the latest arguments regarding the pros and cons of unilateral or bilateral ECT may not be right.
And we would like to take this opportunity to update readers of current developments which may potentially revolutionize or even significantly modify
our thinking about the controversial treatment.
As the author says, the UK ECT review group in 2003 had an important shortcoming of inclusion of all stimulus intensities, leading to a dubious conclusion in favor of the advantages of bilateral ECT. Although we do believe that the uncertainty in evidence exists, the emerging evidence base, particularly in the US and Australia may tilt the balance of opinion and attitudes, more in favor of right unilateral (RUL) ECT with the ultra- brief type of pulse width. Sackeim et al (1) and Loo et al (2) have published in 2008, research indicating that ultra-brief pulse width right unilateral ECT is likely as effective as the conventional (brief pulse RUL) one, in addition to being significantly better in terms of cognitive disability. This is an exciting new development as we believe cognitive disability has consistently been underplayed in the literature on ECT over the years. Robertson and Pryor in 2006 (3), like Mangaoang and Lucey in 2007(4) cite extensive relevant literature suggesting a lot more cognitive damage and disability, undetected by conventional testing. Additionally, if the patients were to be made aware of a potential modality of treatment with significantly less cognitive disability, they may actually make a more completely informed decision. Although it is not difficult to adapt current practice to using ultra brief pulse width RUL ECT by slight modification of the ‘programmes’ settings available on current machines in UK, this detail is clearly beyond the scope of this letter. In conclusion, we do posit that, the need for faster recovery by using bilateral ECT may be more than balanced by the need to deliver the treatment which is less disabling (in terms of cognitive disability) and possibly equally effective. References: 1. Sackeim, H. A., Prudic, P., Mitchell, S., et al (2008) Effects of pulse width and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Brain Stimulation, 1, 71-83. 2. Loo, C. K., Sainsbury, K., Sheehan, P., Lyndon, B. (2008) A comparison of RUL ultrabrief pulse (0.3 ms) ECT and standard RUL ECT. Int J Neuropsychopharmacol, 11: 883-90. 3. Robertson, H., Pryor, R. (2006) Memory and cognitive effects of ECT: informing and assessing patients. Advances in Psychiatric Treatment, 12: 228-237. 4. Mangaoang, M. A., Lucey, J. V. (2007) Cognitive rehabilitation: assessment and treatment of persistent memory impairments following ECT. Advances in Psychiatric Treatment, 13: 90-100. Authors: Dr Mukesh Kripalani, Specialist Registrar, Adult Psychiatry, Northern Deanery. Dr Vinod Chaugule, Consultant Psychiatrist and ECT lead for Tees, Esk and Wear Valley NHS Foundation Trust. |
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