The Role of Bilateral ECT When Right Unilateral ECT Is Inferior

To the Editor: We read with great interest the important results of the trial by Semkovska et al., published in the April 2016 issue of the Journal (1), regarding bitemporal versus high-dose unilateral ECT for depression. While the findings add to the evidence base of the efficacy of right unilateral electrode placement and demonstrate “noninferiority” at the group data level, we should be careful not to dismiss the clinical importance of bilateral electrode placement (2). As noted by the authors, response and remission rates were quite low for both interventions in this study. At the individual patient level, it is likely that a substantial proportion of the 54% of nonremitters in the right unilateral group would have gone on to reach remission had they been crossed over to bilateral placement. In clinical practice, many patients who elect to start ECT with right unilateral placement and who show inadequate response after 1–2 weeks of treatment are switched to bilateral placement with, ultimately, excellent results (3). ECT is a treatment often prescribed for our most severely ill patients, some with life-threatening illness; efficacy should not be compromised for fear of transient cognitive tolerability issues. Right unilateral ECT, both in the form administered in the study by Semkovska et al. and with ultrabrief stimulus waveforms, offers a welcome option for well-tolerated ECT (4). However, for the subset of patients who do not respond to it, right unilateral ECT may actually be inferior.