Electroconvulsive Therapy Versus Pharmacotherapy for Bipolar Depression

To the Editor: The excellent study by Helle K. Schoeyen, M.D., Ph.D., et al. (1), published in the January 2015 issue of the Journal, compares the relative efficacy of a polymedication algorithm with electroconvulsive therapy (ECT) in the treatment of patients with bipolar depression. Despite the fact that their results show the superiority of ECT compared with their pharmacological algorithm on all three assessment outcome scales, the conclusion in their abstract merely states, “Remission rates remained modest regardless of treatment choice for this challenging condition.” An emphasis on a strict, dichotomous remission criterion downplays the clinically significant 74% response rate in the ECT group compared with a 35% response rate in the medication group in this “challenging condition.”

As with the many options in their choice of medications, they chose the ECT treatment technique of right unilateral electrode placement and brief pulse stimuli, a less than maximally efficient treatment form that may have handicapped the ECT arm in terms of both speed of response and remission rate. Their mean of 10.6 ECT treatments to remission is substantially higher than the approximate mean of 6.0 in the electrode placement study published by the Consortium for Research in Electroconvulsive Therapy group (2). In that study, bilateral electrode placement was associated with a significantly faster speed of response than with either right unilateral or bifrontal electrode placements. For the seriously ill cohort of patients enrolled in the Norwegian study conducted by Schoeyen et al., strengthening the efficacy of the type of ECT used would likely have improved the results, further separating the ECT and pharmacotherapy groups.

Schoeyen et al. indicate that the most severely ill (and most suicidal) patients, for whom ECT is most clearly indicated and perhaps most effective, were excluded from their study because of liability and consent issues. But the patients who were included did volunteer. They were entitled to be informed about the most efficient forms of treatments and not to be disadvantaged for their decision. In real-world clinical settings, the option to use the most potent ECT techniques is an important aspect of optimized, ethical care (3).