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

Department of Psychiatry, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA.
The British journal of psychiatry: the journal of mental science (Impact Factor: 7.99). 03/2010; 196(3):226-34. DOI: 10.1192/bjp.bp.109.066183
Source: PubMed


Electroconvulsive therapy (ECT) is an effective treatment for major depression. Optimising efficacy and minimising cognitive impairment are goals of ongoing technical refinements.
To compare the efficacy and cognitive effects of a novel electrode placement, bifrontal, with two standard electrode placements, bitemporal and right unilateral in ECT.
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.
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.
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.

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    • "Proliferation of newborn cells in the rat dentate gyros has also been demonstrated after a single application of ECS (Ito et al., 2010; Madsen et al., 2000). These findings suggest possible beneficial effects of a single application of ECS, which in clinical settings are supported by a number of trials with patients receiving a single session of ECT (Kellner et al., 2010; Thomas and Kellner, 2003). "
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    ABSTRACT: Electroconvulsive therapy (ECT) remains the treatment of choice for patients with severe or drug-resistant depressive disorders, yet the mechanism behind its efficacy remains poorly characterized. In the present study, we used electroconvulsive seizures (ECS), an animal model of ECT, to identify proteins possibly involved in the preventive effect of ECS on stress-induced neuronal atrophy in the hippocampus. Rats were stressed daily using the 21-day 6h daily restraint stress paradigm and subjected to sham seizures, a single ECS on the last day of the restraint period or daily repeated seizures for 10 consecutive days during the end of the restraint period. Consistent with previous findings, dendritic atrophy was observed in the CA3c hippocampal region of chronically stressed rats. In addition, we confirmed our recent findings of increased spine density in the CA1 region following chronic restraint stress. The morphological alterations in the CA3c area were prevented by treatment with ECS. On the molecular level, we showed that the synaptic proteins Homer1 and Spinophilin are targeted by ECS. Repeated ECS blocked stress-induced up-regulation of Spinophilin protein levels and further increased the stress-induced up-regulation of Homer1. Given the roles of Spinophilin in the regulation of AMPA receptors and Homer1 in the regulation of metabotropic glutamate receptors (mGluRs), our data imply the existence of a mechanism where ECS regulate cell excitability by modulating AMPA receptor function and mGluR related calcium homeostasis. These molecular changes could potentially contribute to the mechanism induced by ECS which prevents the stress-induced morphological changes in the CA3c region. Copyright © 2015 Elsevier B.V. and ECNP. All rights reserved.
    Full-text · Article · Apr 2015 · European neuropsychopharmacology: the journal of the European College of Neuropsychopharmacology
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    • "Right-unilateral (RUL) ECT has been shown to cause less short-term memory loss than bitemporal (BT) ECT, but is less clinically effective when given at the same electrical dose relative to seizure threshold [3], [4]. Alternatively, some (but not all) studies have found that bifrontal (BF) ECT causes fewer memory side effects than BT ECT [5]–[8]. In addition, recent clinical research has found that TP-RUL had large effects on heart rate [9], [10], presumably due to direct stimulation of vagal nuclei in the brainstem [11]. "
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    ABSTRACT: The efficacy and cognitive outcomes of electroconvulsive therapy (ECT) on psychiatric disorders have been shown to depend on variations in electrode montages. Conventionally, the right-unilateral (RUL) montage was temporoparietal, originally proposed by d'Elia. Although it was reported to have better cognitive outcomes than the bitemporal montage, it is still associated with substantial memory side effects. Two other RUL montages utilizing a frontal electrode, also proposed by d'Elia, may be more beneficial. In order to investigate this, a high resolution finite element human head model was generated from MRI scans and implemented with tissue heterogeneity. The model was used to compare the effects of three different d'Elia RUL montages. The results suggest that the two alternative placements are likely to result in lesser memory side effects, and may have useful efficacy.
    Full-text · Article · Jul 2013 · Conference proceedings: ... Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Conference
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    • "Most experimental work over the past 3 decades has focused primarily on optimizing ECT treatment parameters (eg, electrode placement, stimulus dose, and pulse width) to produce the best possible balance between clinical and neuropsychological outcomes. These studies unequivocally show that ECT is a powerful treatment option capable of producing full remission where other treatments have failed (Dunne and McLoughlin, 2012; Eranti et al, 2007; Kellner et al, 2010; Loo et al, 2012; Sackeim et al, 2009). However, given that relapse following ECT is a key clinical problem, we carried out a systematic review of all existing evidence, randomized and observational, to provide an overview of current knowledge on this important question. "
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    ABSTRACT: High rates of early relapse following electroconvulsive therapy (ECT) are typically reported in the literature. Current treatment guidelines offer little information to clinicians on the optimal nature of maintenance therapy following ECT. The aim of this study was to provide a systematic overview of the existing evidence regarding post ECT relapse. A keyword search of electronic databases was performed for studies appearing in the peer-reviewed literature before January 2013 reporting on relapse rates in responders to an acute course of ECT administered for a major depressive episode. Meta-analyses were performed where appropriate. Thirty-two studies with up to two years' duration of follow-up were included. In modern-era studies of continuation pharmacotherapy, 51.1% (95% CI=44.7-57.4%) of patients relapsed by 12 months following successful initial treatment with ECT, with the majority (37.7%, 95% CI=30.7-45.2%) relapsing within the first six months. The six-month relapse rate was similar in patients treated with continuation ECT (37.2%, 95% CI=23.4-53.5%). In randomised controlled trials, antidepressant medication halved the risk of relapse compared to placebo in the first six months (risk ratio=0.49, 95% CI=0.39-0.62, p<0.0001, number needed to treat=3.3). Despite continuation therapy, the risk of relapse within the first year following ECT is substantial, with the period of greatest risk being the first six months. The largest evidence base for efficacy in post ECT relapse prevention exists for tricyclic antidepressants. Published evidence is limited or non-existent for commonly used newer antidepressants or popular augmentation strategies. Maintenance of well-being following successful ECT needs to be improved.Neuropsychopharmacology accepted article preview online, 18 June 2013; doi:10.1038/npp.2013.149.
    Full-text · Article · Jun 2013 · Neuropsychopharmacology: official publication of the American College of Neuropsychopharmacology
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